Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SIVEX11I N JOAQUIN LOCAL HEALTH DISTRICT <br /> ; _ �. <br /> 1 E. HAZE,�.I�O>�J�.AVE., STOCKTON, CA <br /> Telephone {209')•,466-6781 <br /> JUN � O ''SSPERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f.WIMNME HEAR E (Complete in Triplicate) <br />_ Application is hereby M� lapgquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San tZqurn pYi�f}y Ordinance No. 549 for sewage or No. 3862 for well/pump and lite Rules and Regulations of the San Joaquin <br /> Local Health District. l <br /> I <br /> 3S" /?c o 1H ' <br />` Job Address ..__. ize PM � <br /> OwnerName l e _/t(v3� Lino L �� <br /> Contrac dress �D [ 7 Z r <br /> License No. �Phone_ <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f`-�1Public n Other ❑ Delta Depth of Grout Seal Type of Grout <br /> INriFn4lation Approx.''Dep I I astern S rface Seal Installed by M <br /> Repair Work Done GType of Pump H.P. ... State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK:' NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is f' <br /> l 1 available within 200 feet) E <br /> Installation will serve: rResidence_ Commercial_ Other <br /> Number of living units Number of bedrooms •" <br /> LA <br /> Character of soil to a depth of 3 feet: Water table depfhj <br /> SEPTIC TANK (11 T; e/Mf ~'ti J -` <br /> YP 9 „ Capacity. No. CompartmentsT <br /> PKG. TREATMENT PLT,oO <br /> s... -x°46 Method of Disposal <br /> la rD stance to nearest: Well Foundation ' � �propectty Line) <br /> LEACHING LINE �C1 No. & Len th of lines <br /> 9 Total length/size <br /> FILTER BED ❑ Distance to'nearest: Well Foundation Property Line yy.; <br /> SEEPAGE PITS I I Depth I 1 _', Size !, Number * ti f <br /> +SUMPS _ ❑ Distance fo nearest: <br /> �Well� i Foundation Property Line 4 <br /> 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 reg <br /> uI do San Joaquin Local Health Di§trict. <br /> Home owner icensa age 'signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ an arson in such ma vier as to be ome subje workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t e following: "I certi that in th or e o he work for w efmft is issued, I shall employ persons subject to workman's compensa- <br /> tion law of Californ . k <br /> The ap licant mus r all rel ion omplet drawing on e e <br /> Signed Title: ..__ y I Date: <br /> FOR PARTMENT USE ONLY <br /> b <br /> Application Accepted by Date —17 O Area F <br /> Pit or Grout Inspection by Date Final Inspection by Date f i <br /> Additional Comments: ? 9I <br /> ❑ Stk 466-6781 • ❑ Lodi` 369-3621 ❑ Manteca H23-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to, Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE ' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT No. <br /> EH 1 -241RE'V.i/n5l <br /> r EH 144-28 <br /> 4 <br />