Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES YEAR-FROM DATE ISSUED <br /> (Complete in Triplicate) k <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 a compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District: "` ' " 5° AF r <br /> 'J 4,4 <br /> ' J �' ' �.Rdc�T�osciYty Lot Size P <br /> Job Address O` <br /> Owner's Named r <br /> Address v d2!� Phone_ <br /> 1'.� 9. � Phone <br /> Contractor <br /> uGLt72- Address License No., <br /> TYPE OF WELL'IPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ' Type of Casing Specifications f'l <br /> ❑ Domestic/Private ❑ Gravel Pack,;- ❑ Tracy t,, T of Grout 11 <br /> [7 Public ❑ Other k ❑ Delta Depth of Grout Seal Type �- <br /> ❑ Irrigation _--Approi. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> Well Destruction D Well Diameter : Sealing Material lisp 501 {- <br /> Depth I , Filler Material (Below 50') ' �J <br /> 'TYPE"OF-SEPTIC-WORKi*NEW INSTALLATION REPAIR/ADDITION F-1DESTRUCTION ❑ availablle(Nolwithin 2W feet.)esm if.public sewer is <br /> ..+r ..rte+. �,a--��- :-n"4%--. :Ys+.•. '.....�. <br /> Installation will-serve�Residence�commercial- -* Other"-- - € <br /> Number of living units: __�- Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: l ILI <br /> " y p' ty 1 No. Compartments <br /> F SEPTIC TANK <br /> Type/Mfg a Ca act Method of Disposal <br /> PKG. TREATMENT PLT. ❑ I <br /> Distance tomearest: Well <br /> Foundation Ap� 1. Line <br /> A <br /> LEACHING LINE No. & Length of lines T m . "�- Total length/size <br /> FILTER BED 11Distance to nearest:,,*, k Well- 4Foundation r�/� �' Property Line <br /> Number i. <br /> SEEPAGE PITS Ll Depth{ Size i <br /> '✓ Foundation Property Line <br /> SUMPS ❑ Distance to nearest: Well r <br /> DISPOSAL PONDS ❑ <br /> k ► <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 tKe fdllZiI "I certify that in the perfdrrriance-of the`wo°rk_for which this permit is issued, I shah 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 /> a req red inspections. Complete drawing on reverse side. <br /> The applicant must call forl l _ <br /> Dat : <br /> Title: <br /> Signed • <br /> FOR DEPARTMENT USE ONLY ..��11 <br /> Date / Area �/7 <br /> r Application Accepted.by T <br /> y Final inspection'by Date���` <br /> Pit or Grout Inspection by Date <br /> ,Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3511 ElManteca 823-7104 oTracy .835x63$5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601'E. Hazelton Aver P.O..Sox 2009: Stk., CA 95201. _- •_ w.. a. <br /> FEE l CK# RECEIVED BY DATE PERMYT`NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH _ . <br /> 13-24 MEV. /951 f <br /> P' EH 14428 .. . <br />