Laserfiche WebLink
APPLICATION FOR PERMIT fi <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />it PERMIT EXPIRES�1 YEAR 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 />C <br />^"I .." . City <br />l �7 N <br />Job Address ��- y Lot Sizel4_kP_ PM <br />Owner's3 Name <br />r'i �I Address �� .Phone!_, <br />Contractor/ <br />RECEIVED' BY PATE PERMIT' NO. <br />.._4 <br />License Na, <br />TYPE OF WELL/PUMP: III NEW WELL J WELL REPLACEMENT f_] DESTRUCTION 0 <br />PU <br />SYSTEM REPAIR C] OTHER C1 I 1 <br />DISTANCE TO NEAREST: SEPTIC TANK . <br />�^•` SEWER LIN P05AL FLO. PROP_: LINE = <br />FOUNDATION <br />ti �. AGRICULTURE WELL - OTHER WELL S/SUMPS <br />tr <br />WELL <br />AREA ONTPIFICAT10NS <br />© Indusi-a-1 <br />m <br />/C <br />❑Manteca Dia. WeIIExcavon _ Dia. of Well Casing <br />L) Domestic/ Private <br />Gravel Pack <br />J <br />Type of Casing _.__ __.. _....... Specificationi <br />❑ Public <br />s Other <br />,w <br />I Delta -Beth of Grnut Seal <br />Type of GroutC <br />Irrigation <br />-_Approx. Depth <br />C Eastern Surface SeaRepair <br />Work Done <br />❑ Type of Pump :............... <br />' H.P. LState <br />Well Destruction <br />C7 Well Diameter <br />j „ Sealing Material (top 50') <br />DI(ipth.­1111 <br />Filler. slaw 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION <br />..7 PAIR/ADDITION ESTRUCTION U fNo septic system permitted if public sewer is <br />' <br />'f'''•"- available within 200 feet.) <br />Installation will serve: <br />Residence _r -Commercial <br />_ Other <br />Number of living units: __.�p . Number of bedrooms <br />Character of soil to a depth of 3 feet;,_,_ <br />_ ... __„,,,,,,,,_Water table depth (' <br />SEPTfC TANK <br />CIi Type/Mfg <br />................. <br />_ ^rr Capacity— ,,... No. Compartments <br />PKG. TREATMENT PLT. L7 <br />.. , : <br />I, <br />Distance <br />Method of Disposal <br />i.. <br />to• -nearest: <br />_ Wall Foundations; _ Property Line <br />LEACHING LINE <br />Y” i No. & Length of lines 1 - _ - u- Total lengthlsize �I <br />FILTER SED- `` <br />_1_1 Distance,to nearest: <br />- Well t� -__ :,- �� Pro / <br />foundation party Line .....I...Q <br />SEEPA& PITS <br />C <br />I Depth /�' ��,.Size <br />`' i <br />SUMpS <br />f i <br />Distance to 'nearest!, <br />Number — <br />Well ©b Foundation -..• U+ Property Line I <br />DISPOSAL PONDS <br />IJ <br />I rlereoy certrty that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br />rul&s and regulations of the San Joaquin Local Health District. t t to <br />Home owner or licensedlagent's signature certifies the'following: "I certify that in the performance of the work for which this pertrdt is issued, I shall not <br />employ any person in such manner as to become subject to workman',s compensation laws of.Caifornia." Contractor's hiring or sub -contracting signature <br />certifies the following: "I Certlfy that in the performance of the work for which this permit is issued, I shall employ persons subiect to workman's compensa- <br />tion laws of California." <br />The applica must cal{ f all requir d inspections, Complete drawing on reverse side. i <br />T�rorir'w _ �'• ..... Date: <br />Signed X Title: <br />FO DEPARTMENT USE ONLY i <br />Application Accepted by ...... Date <br />/ II <br />E Pif r Grout Inspection by Date 6� Final Inspection by ate3`. <br />I <br />Additional Comments:. <br />C §tk 466-6781 Cl Lodi 3693621 ❑%Manteca 823.7104 O Tracy 8356385 <br />Applicant - Return all copies':to: Enviropmentai Health Permit/ Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 iI <br />+ EH 13-241REV, <br />n. EH 1426 ;. <br />FEE INFO AMOUNT DUE' -A <br />AMOUNT REMITTED' <br />CAH <br />RECEIVED' BY PATE PERMIT' NO. <br />