Laserfiche WebLink
N, <br /> i <br /> j <br /> APPLICATION FOR PERMIT <br /> II SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �I 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> -� Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> . This <br /> cation is <br /> Application is he+eby made to thle San Joaquin 0[d°nancle No.Districtealth 49 for sewage to construct <br /> or No 1862 for well/dpump and the Rules and all the work IR Regulationsofof the San'Joaquin + <br /> made In compliance with San Joaquin County t <br /> Local Health District. <br /> �-•� City Lot Size PM <br /> Job Address <br /> Owner's Named ��I� Address <br /> q/3� t*S� RirbCrE b,e Phone <br /> 2,9-2,74 Phone 6 -3 7 <br /> �C Eeilae�l Address 27 0, ���� �� License No,.r/ <br /> Contractor,__� <br /> NEW WELL I-] <br /> WELL'REPLACEMENT © DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: OTHER ❑ { <br /> PUMP INSTALLATION'❑ 'j± .R ,[SYSTEM' REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r L FLD. PROP. LINE <br /> FOUNDATION ; AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELD PROBLEM AREA TRUCTION'SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom 'i ElMantec Dia. of'Vllell Excavation <br /> cy Type of Casing ' °' Specifications' <br /> ❑ Domestic/Private ❑ Gravel Pack ` .,Type of Grout <br /> l-1 Public <br /> Other C1 Delta Depth of Grout Seal <br /> _� A r Depth I 1 Eastern Surface Seal'lnstalled�by <br /> 1 1 Irrigation . pp `< State Work Done <br /> Repair Work Done O Type of ump H.P. <br /> Sealing Material (top.50') <br /> l Well Destruction ❑ Well Diameter g 5 <br /> Depth ' Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ! REPAIR/ DESTRLtCTION I I availabNo le+c system w thin 200 fe ti;pubfier is <br /> installation will serve: Residence Commercial— Other <br /> !Number of living units: — Number off bedrooms_ _-- <br /> i t Water table depth <br /> Character of soil to a depth of 3 feet: F <br /> l' y �'"""" capacity No. Compartments <br /> j SEPTIC TANK ❑ ',[!Type/Mfg -ter <br /> Method of Dispos <br /> PKG. TREATMENT PLT. ❑ == <br /> Pro ert .Line <br /> Distance to nearest: Wel! Foundation.. P Y <br /> Q Total length/size 4 <br /> LEACHING LINE Lemli No. & Length of lines { �� <br /> Distance to nearest: Well �d Foundation Ad Property Line l��. <br /> ! FILTER BED ❑ II i <br /> SEEPAGE PITS l'1 �I Depth «' t Size l O Number j + <br /> SUMPS ,Distance to nearest: ; Well I/Op Foundation Property Line ' <br /> DISPOSAL PONDS 0!.1: - <br /> ' repared this application and that the work will be done in accordance with San Joaquin county ordinan <br /> I hereby certify that I have pces, state laws, and, <br /> I rules and regulations of the San Joaquin Local Health District: <br /> ' Home owner or licensed agent's signature certifies the following: 11 certify that in the performance of the work for which this permit is issued, I shall not,: <br /> signature <br /> employ any person in such manner as to bcome subject to workman's compensation laws of California.'" Contractor's shin or sub to wo�kmanlscompensa <br /> certifies the following:"I certif that in the performance of the work for which this permit is issued, I shall employ psubject <br /> tion laws of California." ill <br /> The applicant must call for all required inspec'ons. Complete drawing on reverse side. 4' <br /> Title: Date: Q <br /> Signed X I <br /> p� s FOR DEPARTMENT USE ONLY t\p8_,A—��• , �� .Area � <br /> F <br /> Application Accepted by Date <br /> I <br /> Date <br /> Pit or Grout Inspection by Date Final Inspection by <br /> �I <br /> Additional Comments: 1�' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 <br /> Applicant- Return all copiei to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 <br /> CK RECEIVED 8Y DATE PERMIT NO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> a,EH 1321(REV.1/X51 © `' N. <br />