Laserfiche WebLink
1 Ii <br /> APPLICATION FOR PERMIT <br /> SAN 'SOAQUIN LOCAL HEALTH DISTRICT <br /> I, 'y <br /> 1601 '.E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 JUL 19$ <br /> jj PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ENVIROMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woripIT&(efltf IgAPPlication 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. V <br /> �� <br /> Jab Address J C'ty i 1, Srze PM <br /> 3 - o ta-I <br /> Owner's Name Address -_ <br /> ' Z License No. Z ' '`t-Phone <br /> \Jbontractor L ddress <br /> TYPE OF ELLIPUMP: N WELL LlWELL REPLACEMENT ❑ DESTRUCTION F]W. <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ € <br /> 61STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE <br /> I i FOUNDATION AGRICULTURE WELL OTHER WELL PIT,'/SUMPS "� <br /> E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> LJ Industrial C]'Open Bottom Ll Manteca Dia. of Well Excavation Dia. of;Well Casing <br /> Domestic I Private ❑hGravel Pack ❑ Tracy Type of Casing Specifications <br /> f] Public ❑,Other Cl Delta Depth of Grout Seal Type of Grout — <br /> I#I Irrigation / i Approx. Depth I.) Eastern Su�acce Seal Installed by - <br /> Repair Work Done lB' Type of Pump s H•P !�Y State Work Done F <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> DeIpth + Filler Material (Below 50'1 <br /> TYPE OF SEPTIC-WORK: ANEW;INSTAL{ATION l-1--REP..AIRLADDITION,1 I `^,DESTRUCT ION l 1 (No septic system permitted it pdblic sewer is <br /> +a (r available within 200 fe 6t.) <br /> Installation will serve;'.`Reside6c — Commercial Other " <br /> r <br /> Number units: Number of-bedrooms— "'" " �" �"""! <br /> !Character of soil to a depth of 3 feet: Water table d nth t�] <br /> SEPTIC TANK ,''t'C1]I\Type/Mfg Capacity— <br /> ( <br /> apacity No. Compartments <br /> v <br /> PKG. TREATMENT PLT. 0 �i Method of Disposals _ l <br /> f , <br /> i tf I distance to nearest: Well Foundation Property.Line <br /> i <br /> LEACHING LINE112 No. & Length of lines Total length/size— <br /> FILTER <br /> ength/size i rn <br /> r 1 � _yy <br /> FILTER BED ❑; Distance to nearest: Well Foundation . Property Line - <br /> SEEPAGE'PITS """— Number <br /> 4 J n <br /> SUMPS L� .Distnde iri`•'nearest: Well Foundation Property Line 4 p4 <br /> I a r , rYt, 1, <br /> DISPOSAL PONDS ❑ <br /> {;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 /> r <br /> rules and regulations of a San Joaquin Local Health Di§trict. <br /> Home owner or li nsed age 's signature certifies the following: "I certify that in the performance of the work for which this permit isissued, I shall not <br /> employ any pe on in such ma ner as to be s " ct to workman's compensation laws of California." Contractor's hiring,or sub-contracting signature <br /> certifies the f lowiri : "1 certif at in a rfotr a e of t or which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of alifor, <br /> The applica t mu a r A req e t ns. Co plate drawing on r si <br /> Signed X Title: Date. <br /> R EPARTMENT USE ONLY <br /> Date Area ' <br /> Application Accepted by s „ <br /> Pit or'Grout Inspection by Date Final Inspection by �IY� <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 3694621 ❑ Manteca 823-7104 Cl Tracy 835-6385 <br /> Applicant- Return all copiesf to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> r <br /> t.EH 13.244F1EV.1/85) <br /> EH 14-28 <br />