Laserfiche WebLink
k <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE'LTON AVE., STOCKTON, CA <br /> i Telephone (209) 466-6781 <br /> k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> l. <br /> (Complete in Triplicate) <br /> t <br /> bed. This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descri <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 /> I Local Health District. . <br /> j City Lot Size — PM <br /> Job Address <br /> Phone <br /> SDI <br /> Owner's NameAddress <br /> tl r7 Q Phone I i <br /> Contractor's Name �, -- License No. � <br /> TYPE OF WELLIPUMP: NEW WELL LJ REPLACEMENT ❑ DESTRUCTION El <br /> " "pl1MP-INSTALCATION �— SYSTEM REP IR ❑ ..OTHER El = — <br /> SEPTIC_ TA1VK_ SEWER LINES DISPOSAL FLD. PROP INE <br /> DISTANCE TO NEAREST:.. <br /> — -V OTHER WELL PITS/ LIMPS \' 1 <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia."of Weil Casing <br /> LI Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> MPublic ❑ Other El Delta Depth of Grout Seal <br /> ❑ Irrigation --4ppro{. Deptth�, ❑ Eastern Surface Seal Installed by � R <br /> Repair Work Done ❑ Type of Pump H.P. State Work"Done <br /> V-1, <br /> Well Destruction ❑ Well DiameterG Sealing Material {top 501 <br /> Depth� Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ", DESTRUGTIO a ailseptiblewsh n m rented if public sewer is ; <br /> eeM <br /> Installation will serve: Residence Commercial Other u <br /> I, !- !/ <br /> Number of living units: Number of bedrooms A , <br /> Character of soil to a depth of 3 feet: r` W. <br /> table depth <br /> SEPTIC TANK ❑ Type/Mfg. -_ �" 4 Capadity No. Compartments <br /> .e' J <br /> PKG. TREATMENT PLT. 114 ; r f' ,'� Method of Disposal <br /> Distance to nearest:,` Well A Foundation Property Line <br /> % t% F F: <br /> t r �... Total lengthlsize <br /> LEACHING LINE ❑ No. &'Length ro#.;lines <br /> r� .Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well f <br /> R <br /> SEEPAGE PITS ❑ Depthi Size f f Number <br /> SUMPS [5Distance to nearest: well/ f� Foundation Property Line <br /> DISPOSAL PONDS ❑ .""I / <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`the,4611owing: "I certify that in the performance of the work for which this permit is issued, I shall 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." f <br /> The applicant ust c 11 for all requ i"speections. Complete drawing on reverse sid <br /> Signed Title: <br /> r( r Date: <br /> ' FOR DE RTIIM1ENT USE ONLY <br /> Date Area <br /> Application Accepted by Dated E" <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 y ❑Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> i <br /> FEE CK RECEIVED BY DATE PERMIT"N0. <br /> LINFOAMOUNT OUE AMOUNT REMITTED CASHg5 �EH 13-24(REV.10/83! ` 6 .r <br /> i EH 14-26 - <br />