Laserfiche WebLink
� £ , <br /> APPLICATION FOR PERMIT PAYMENT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA DEC 12 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSLAWRONMENTAL HEALTH <br /> (Complete in Triplicate) PERWAERVICES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 'so, ! � !qdCity may' C' Lot Size PM i <br /> Owner's Name a Address af-2 AAA*6w ��Gr, Phone <br /> Contractor Address.'/72"_.Z License No.yl _:6_Phone009­9*56 <br /> TYPE-OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1} DISPOSAL FLD. PROP. LINE "` 4 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑Ppen Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing <br /> 1 Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —!—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done so Type of Pump H.P. State Work,Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top <br /> Depth Filler Material (Below 50'1 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑r DESTRUCTION-El (Nd septic system permitted if public sewer is <br /> available within'200 feet.) <br /> Installation will serve: Residence_ Commercial�` Other -, t <br /> Number of living units: Number of bedrooms _.•„ <br /> Character of soil to a depth of 3.feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg - - Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 4 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line + <br /> t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED E"❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1:1, Depth Size Number r <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS e❑ I <br /> I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in sucFi mariner as to become subject to workman's compensation laws of California,"Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certifVthat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." i , 3 <br /> The applicant must call for all required inspections. Complete drawing'—on reverse side. ; <br /> Signed X �,_ <br /> et.. Title:9G�7f,�1�'tL1,-J Date: <br /> FOR DEPARTMENT USE ONLY <br /> ) <br /> Application Accepted by ; ` Date Area AD/11Z <br /> Pit or Grout Inspection by Date Final Inspection by _ __Date� sy <br /> In <br /> Additional Comments: <br /> ❑ Stk 466-6781 ElLodi 369-3621 LlManteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> INFO K 0 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> +EH1324(REV.r/a5l <br /> EH 14.26 1-?q7_k46- <br /> I <br />