Laserfiche WebLink
h <br />W <br />APPLICATIOW F_OR PERMIT <br />SARI JOAQUiN LOCAL HEALTH DISTRICT <br />1601 E. -HAZEL T ORI AVE., STOCKTON, CA <br />Telephone (209) 486-6781 <br />PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED <br />t <br />Xomplete.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., . 1 <br />LSA/'� Lam. I. ,,�I'. :...\i.�j rs �., . !1- p� <br />Job Address city <br />­teA, &W/ Lot Size •+.� SCE' -"-J PM <br />w {Owner's Namesee 12— Address <br />-�— Phone <br />Contractor's NameLicense No. �S'^ <br />TYPE nc WELL/PUMP: ` Phone W it '-9'G: G1 <br />NEW WELL �� <br />PUMP INSTALLATION ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK <br />-2/ <br />INTENDED USE TYPE OF <br />WELL REPLACEMENT LJ DESTRUCTION ❑ <br />=4 SYSTEM REPAIR ❑ OTHER ❑ <br />SEWER LINES DISPOSAL'FLD. PROP. LINE <br />AGRfCULTUAE WELL_ OTHER WELL PITS/SUMPS <br />WELL PROEsLt 4 AREA- 1, CONSTRUCTION SPEGIFICATONS <br />❑ <br />in: <br />❑. Open Bottom ❑ Manteca+a --e11-Excavation <br />❑ Domestic/ Private Dia. of Well Casing <br />❑ Public El Pack ❑Tracy *Type of Casing I <br />❑ Othet Q belts - Specifications <br />Depth of Grout Seal `"�"� Grout <br />of Gto <br />Irrigation ­-Approx. Depth ❑ Eastern Surface Seal Installed by! <br />Repair Work Done ❑ Type of Pump I H.P ' <br />Weil Destruction E3 Well diameter State Work Done <br />sa Sealing Material (top 50'1 r <br />k Depth S i Filler Material (Below 50') 1 01� <br />TYPE OF SEPTIC WORK; NEW INSTALLATION 96 REPAIR/ADDITION ❑ DESTRUCTION <br />' Li(No <br />within 200 feet.) <br />(No septic system Permitted if public sewer is <br />fstaliatien will serve: Residence — Commercial <br />, }--=-----� <br />Number of living 'Units,- Number of bedrooms r <br />Character of soil to a depth of 3 feet:�, <br />SEPTIC TANK _ / t Water table depth---/ 0 <br />[!d' Type/Mfg _f&F/2 Capacity-,:?-$��U No. Compartments Z <br />PKG: TREATMENT PLT. ❑ <br />` 1 i Cx7y t Method of Disposal �� � <br />Distance to nearest: Well Z-Amie Foundation _ / O. <br />Property Line l� <br />t <br />i <br />LEACHING LINE <br />FILTER BED <br />SEEPAGE PITS <br />SUMPS - <br />DISPOSAL PONDS <br />Ll No. & Length of lines a 1 i <br />Total length /size_.?O,�« <br />W,I'c/rC/7)"Disiance to nearest: Well _4rxv Foundation'-Z2� Property Line <br />i 1 of — <br />1 L7 Depth I Size {^ a Number <br />' ❑ - Distance to nearest: Well _i - Foundation i <br />Property Line _ <br />I nereny 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 following: "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 />tionAaws of California." <br />The app:�'�'St`calf forall required inspections. Complete drawing on reverse 'de. Y <br />Sign d } <br />F Title: Date: <br />/s FOR DEPARTMENT USE ONLY <br />:A Ii. Vtion Accepted by. v" <br />Datet'Area <br />Pit or GTbut Inspection by F <br />Date Final Inspection by Date li <br />Additional Comments: ( { <br />❑ Stk 466=6781 ❑ Lodi 369-3621Manteca 823-7104 ❑ Tracy 635-6385 <br />Applicant - Return all copies to: Environmental Heafth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />- <br />FEEIMO '6---- �``�`AMOIINT'gEMITTED <br />INFO "RECHVED-BY- .. . � - - - CASH DATE PEiiMIT°NO.TEk 13-20REV- 1Uf631 t - �1 <br />EH 1426 t yl tO <br />