Laserfiche WebLink
APPLICATION,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y , <br /> „. (Complete in Triplicate) <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 - ",# 'GTT/ City I '� Lot Size d/ PM +' r 65 <br /> r Owner's Name t5Il <br /> e�P...,..__ /fe Address S/ w Phone ,, <br /> Contractor 15-C-4� Address i License No. Phone y <br /> PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMPINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NE F�OU <br /> ANK' t SEWER LINES DISPOSAL FLO. i PROP. LINE <br /> r N AGRICULTURE.WELL._ _OTHER.WELL--. - -. - PITS/SUMPS U <br /> INTENDED USE. '\ TYPE OF WELL LEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> � a <br /> ❑ Industrial AJ ❑ Open Bottom ❑ Manteca pia..of Well Excavation -•-r'Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ing Specifications �r <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout :Type of Grout <br /> ❑ Irrigation ; -Approx. Depth ❑ Eastern Surface'Seal Installed by F,.. <br /> Repair Work Done ❑ Type of Pump H.P. State Work pone <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth. Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Iavailable within"200 feet.i <br /> Installation will serve: Residence'_ Commercial_ Other <br /> Number of living units: Number of bedrooms-+ _ m <br /> >ry, <br /> Character of soil to a depth of 3 feet: Water tablet depth <br /> SEPTIC TANK 1A Type/Mfg 4-L Capacity I b No. Compartments <br /> PKG. TREATMENT PLT. O t ��J��r,.�� Method of Disposal <br /> Found <br /> f Distance to nearest: Well ation. �r� Property Line 2� 1 <br /> � r <br /> LEACHING LINE "' N0' & Len9th of lines � Total length/size { <br /> FILTER-BED C1 Distance to nearest: Well J00`�Foundation­t QQ- Property-Line <br /> 4 ' I <br /> kSEEPAGE PITS ❑ Depth Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Line <br /> g DISPOSAL PONDS ❑ ' <br /> I hereby certify"that I 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 no <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that 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." <br /> Thei.applicant must call for all require inspecti ns. Complete drawing on reverse'side" <br /> ' Signed X[ _- Title: ©I�A)4::g..- Date: -I+7z <br /> s — <br /> { 3 FOR DEPAR ENT USE ONLY p <br /> f Application Accepted by • Date ! ^3l Area <br /> Pit or Grout Inspection by Date Final Inspection b Dat12--i <br /> a <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 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 <br /> FI <br /> I JK EE <br /> INFO' . AMOUNT DUET--• --AMOUNT fIEMITTED —CSH �REC7 i1?ED`BY ""pATE'�T PERI4IIIT NOS' <br /> + EHM24(REV.rinS� <br /> EH 14-25 / _( /(7� ,S/7 <br /> i <br />