Laserfiche WebLink
t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ' <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <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 4170.7 City r Lot Size - PM - <br /> me s r <br /> � Owner's Na:me � � Address Phone <br /> Contractor �' � 1-17197 Address N ,' ! � License No.7�Lo;—Phone <br /> TYPE OF WELT./PLIP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ <br /> PUMP INSTALLATION D SYSTEM REPAif❑ ` OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION _. __ AGRICULTURE WELL OTHER WELL PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <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-I Public ❑ Other n Delta Depth of Grout Se`all �, Type of Grout <br /> I I Irrigation . _-Approx, Depth t I EasternSurface Seal Installed by _ <br /> Repair Work'Done U Type of Pump H.P., State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') r� <br /> Depth Filler Material I8elow,,50'h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] -REPAIR/ADDITION ( DESTROCTION t-I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence`� Commercial— Other <br /> Number of living units: - Number of bedrooms 3 re � <br /> Character of sail to a depth of 3 feet: ��a.rt ' '' ; Water table depth < !n <br /> SEPTIC TANK LlType/Mfg f' � �� _ Capacity r��­61 Na. Compartments V <br /> i' PKG. TREATMENT PLT. ❑ r Method of Disposal <br /> (� . <br /> Distance to nearest: Well tJ�✓ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Notal length/sire <br /> L _F ti v� f..__ <br /> FILTER BED ❑ Distance to nearest: Well��,tFouu ndation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number_ <br /> SUMPS 0 Distance to nearest: Wells Founcation Property Line <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 regulations of the San Joaquin Local Health District. r,- 11 <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 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," .11` <br /> The applicant must call for all required inspections, Compneta drawing on reve a side. <br /> Signed X IAA Title: Date: <br /> r AOR DFOARTM NT U E ONLY-, <br /> Application Accepted by` Date ( Area Mf <br /> k Pit or Grout Inspection by �. Cate Final Inspection by! 'E N' Data//W? <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 lf301 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY `\yyyl�DATE PERMIT'N0. <br /> + EH 13.24(REV,I/R 5) 'Y q f �► "9 <br /> F EH 14-28 ♦ / y <br />