Laserfiche WebLink
4 <br /> APPLICATION FOR PERMIT ! M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT !� I <br /> 1601 E. HAZELTON AVE., STOCKTON, CA OCT 1 G 1989 <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> E' (Complete in Triplicate) PERy1L1,g5VV+�ES <br /> Application is heteb made to the San Joaquin Local Health District for a permit to construct and/or install the work herein escn a is application is <br /> App' y <br /> made in compliance with San Joaquin CoaRty Ordinance No.549 for sewage or No. 1862 for well!pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. (l i <br /> Lot Size PM <br /> City <br /> Job Addres <br /> Phone 1 <br /> Address <br /> Owner's Name -�� ' <br /> Address' �� License No. <br /> �a Phone <br /> ContractorDESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: NEW WELL;❑a.a.s � WELL REPLACEMENT Li <br /> SYSTEM REPAIR OTHER ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PlTSI5UMPS <br />! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation } <br /> ❑ Industrial Specifications <br /> ❑ Gravel Pack ❑ Tracy Type of Casing <br /> )pomestic/Private _ Type of Grout_. -- C?s7 <br /> F1 Other n Delta Depth of Grout Seal <br /> I 1 Public + - VI' Surface Seal Installed by <br /> I I Irrigation ���--Approx. Depth- � I 1 Eastern <br /> —R-^ - --.---,- ,.-- State Work Done CIC <br /> Repair Work Done Type0. <br /> Sealing Material (top 50'1 T <br /> Well Destruction El Well Diameter <br /> Depth I Filler Material(Below 50')€ - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITIDN l�lw DESTRUCTION CI i iNo availablelc system permit <br /> wi within 200 feet.led if public sewer is <br /> III _Installation will serve: Residence Commercial Other��� ri - �' `" <br /> Number of bedrooms I <br /> Number of living units: Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments l� r <br /> Capacity <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation �r <br /> j :. Total length/size �I <br /> f LEACHING LINE (7-1 No. & Length of lines <br /> E Foundation Property Line <br /> FILTER BED LI Distance to nearest: Well <br /> I <br /> 1 SizeNumber <br /> SEEPAGE PITS I I Depth Property Line <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> Thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> I state laws, and <br /> r rules and regulations of the.San Joaquin Local Health District. <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 signature <br /> shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." ploy cohiring <br /> subject to oorkmant1s sub-contracting <br /> the following: "I certify that in the performance of the work for which this permit is issued, i shall employ persons <br /> I tion laws of California." s <br /> The applicant I for all r uir d inspections. Complete drawing on reverse side. <br /> Title: Date: - <br /> Signed X_.�s - <br /> i <br /> F FOR DEPARTMENT USE ONLY 2f <br /> Date Area <br /> Application Accepted by ` <br /> 10flY <br /> Pit or Grout Inspection by Date <br /> Final Inspection by ate O <br /> Additional Comments: <br /> ! ❑ Stk 486-6781 El Lodi 369.3621 ❑ Manteca f923 7104 ❑ Tracy 635-5385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED Y ' CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 13-24(REV.1/951 <br /> 3 S <br /> EK 14-20 . <br />