Laserfiche WebLink
i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA OJ <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I <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. <br /> Job Address City Lot Size PM <br /> Owner's Name Address Phone <br /> f r <br /> l �( C�Cz <br /> Contractor d e [ 2 �3 i ansa No �J Phone <br /> TYPE OF WELL/PUMP:. -- ,-NEW WELL.C,.�­- -»-WEL-L REPLAGEMENT•❑ -_ •-DESTRUCTION•❑-- -----•----- -- <br /> i PUMP INSTALLATION ❑`' IYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER NES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRI LTU RE WELL OTHER WELL - PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBL REA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottbm •``� .❑ Mant a Dia. of Well Excavation Dia. of Well Casing e <br /> ❑ Domestic/Private ❑ Gravel Pack .,__L1-iTra Type of Casing * Specifications <br /> FI Public Cl Other - <br /> _ ❑ID ta, Depth of Grout Seal Type of Grout v <br /> I I Irrigation a —.-Approx. Depth__ I I _stun'-;�' Surface Seal installed by _ <br /> Repair Work Done ❑ Type of Pump H. ., State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 [� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO 1.1 REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is l� <br /> avail able within 200 feet.l <br /> Installation will serve: Residence' Commercial_ Other <br /> Number of living units: Number of bedrooms rL 1 i <br /> Character of soil to a depth of 3 feet: Water table depth V <br /> SEPTIC TANK ❑ Type/Mfg ti Capacity ! No. Compartments <br /> PKG. TREATMENT PLT. ❑ k ` Method of Disposal i <br /> t <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size > <br /> FILTER BED ❑ Distance,to nearest: Well Foundation i Property Line <br /> SEEPAGE PITS I I Depth Size f Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Joaqu'in'Local Ne81th Diltrict.`"` -• -�.� --� . I <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;1 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." , <br /> a The applican ust tail for required ' spections. Complete drawing on reverse side. f cgs �y <br /> Signed X t 1 Title: t Date: <br /> FO EPARTM USE ONLY i <br /> Application AcVIM Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> »- <br /> ­FEE- - AMOUNT-61JE- """°"AMOUNT REMITTED`" .—.CK- - "RECEIVED BY DATE PERMIT'NO. " ? <br /> INFO CASH <br /> +. Ht3-241HEV.r,�5, �h l -q- eta -a98b <br /> EH 14-2a <br />