Laserfiche WebLink
GC.o r <br /> APPLICATION FOR PERMIT <br /> SAN JOAaUIN LOCAL HEALTH DISTRICT 7 <br /> 1601 E HAZETON AVE., STOCKTON, CA 's L? <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ( (Complete in Triplicate) <br /> ti <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. a r <br /> Job Address � -� City` Lot Size + � PM } <br /> Owner's Namey � .__ ?C�/�� Address �-S� `. A6= /o+Phone Z <br /> ContractorAddress o2�0}� ��/,Lc�J� ' License No. f!e Phone�62 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION� SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONS�'� AGRICULTURE WELL OTHER WELL PITS/SUMPS 74�� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R—Z Dia. of Well Casing <br /> 4 x;>Womestic/Private, A Gi'_vel Pack' ❑ Tracy Type of Casing Specifications <br /> �; � 0#her T 1:1Delta Depth of Grout Seal Type of Grout <br /> Ci <br /> 01 rrigation s pprox. Depth.,El Eastern Surf age Seal Installed by N <br /> 90 <br /> Repair Work Done ❑ Type of Pump H.P. , State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth ' Filler Material (Below 501 =• <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> F available within 200 feet.) , <br /> Installation will serve: Residence Commercial_ Other <br /> r,.�.5 <br /> Number of living units: Number of bedrooms ;Z:A r -W <br /> Character of soil to a depth of 3 feet:' I -'Water table depth <br /> SEPTIC TANK ❑ Type/Mfgi. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i 4 i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line .f I <br /> LEACHING LINE ❑ No. & Length of lines Total length/.'size <br /> FILTER BED ❑ Distance to nearest: Well Foundation gE Property Line <br /> SEEPAGE PITS ❑ Depth I Size t y �Number " <br /> SUMPS El Distance to nearest: Well .itFoundation- �-- Property�Line <br /> �. <br /> DISPOSAL PONDS, <br /> hereby certify that I have prepared this application and that the vJo4k will be done in_.accordance with San Joaquin county ordinances, state laws, and f' <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: ','I certify iFiat,in thet performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman'7s compe'nsatiorf laws of'Callfornia."Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the workfoi ch this peri6it4s issued;-,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant required ins tions._Complete drawing on reverse ide:�r}-�. & <br /> SignedTitle:„_,..__�—!i` � ..— Date: - <br /> 4��n �jjl FOR DEPARTMENT;USE ONLY of <br /> Application Accepted by r ". Datet`7 f 12­;--k7 Arsa j <br /> Pit or Grout Inspection by Date -17(07" Final Inspection by' - Date <br /> Additional Comments kln Zh,, f{ r +' l <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621`L ''❑'MAnteca" 8231104 ..r-. ❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO --AMOUNT DUE tomAMOUNT-REMITTED~ � CASH f ---RECEIVE '[­_D BY"" <br /> DATE(/''] PERMIT N0. <br /> + EH 13-241REY.7/asl 1 / /�� / S <br /> EH 14-26 111 lJ�--� /. ' <br />