Laserfiche WebLink
r 'M <br /> APPLICATION FOR PERMIT <br /> PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate),44> w. 3 <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—c" FiES <br /> '�... + 1ti? - ,� I ;;".) +. : .. <br /> T. <br /> Job Address j *t <br /> 4 City Lot Size F PM_ <br /> Owners Name w' v _ Address }/r --_ Phone <br /> Contractor's Name License No. Phone J <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION­fl--- ----SYSTEM REPAIR-© " " OTHER O <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial L3 Open Bottom © Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gnavel Pack ❑ Tracy Type of Casing Specifications <br /> "� ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grouts <br /> ❑ Irrigation Approx. Depth i❑ Eastern Surface Seal Installed by U� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r <br /> Well'Destruction It Well Diameter Sealing Material (top 501i 6 <br /> Depth - -.'r-.Filler-Material-(Below-50) W <br /> F TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION septic system permitted if,public sewer-is.,,- <br /> - ( available within 200 feet.) f f <br /> Installation will serve: Residence J.. Commercial Othe_t <br /> Number of living units: Number of bedrooms ��- r <br /> Character of soil to a depth of 3 feet: r--r'ZTJ _ _Water table depth <br /> �V�flOQ <br /> SEPTIC TANK C9- Type/Mfg Ca_ pacify No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Dis osal <br /> Distance to near t: Well` Foun ation I_-p Property Line�._—_ <br /> . �)0 )tj <br /> LEACHING LINE 4 ❑ No. & Length of lines r s Total length/size <br /> FILTER BED 0 Distance to nearest: Well' { Foundation Property Line o� <br /> ! I t k lr- <br /> M SEEPAGE PITS O .Depth r i Size Number <br /> SUMPS * YO `Distance to nearest:` Well. '�" foundation" * Property Line <br /> DISPOSAL PONDS:.-._._-❑ M § <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 following: !'I certify that in the performance of the work for which this permit is issued, I shall not <br /> empl 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 following:"I certify that in the performance of the'vvork for which this permit is issued, I shall employ`persons subject to workman's compensa- <br /> tion laws of liforma.' ;3' <br /> The applicant m call fo II re fired ' F sett n F C' to drawing on reverse si e. a <br /> SigneB Title: Date: <br /> HI _ <br /> g7 rr Z r FOR DEPARTMENT''USE ONLY <br /> Application Accepted by y � Date ` i Area D� <br /> „ - ate^�' �� i!" G-/ "�_' G D <br /> r :Pit or Grout Inspection by Date FmiM Inspection by (ill <br /> r <br /> -Additional Comments: <br /> ❑-Stk 466-6781'-'` ❑ Lodi 3621 11 Manteca 623-7104 ❑ 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 /> a FEE — AMOUNT DUE AMOUNT REMITTED K 1 RECEIVED BY' <br /> J­'/_':)_91 DATE PERMIT-AO.' <br /> ._ ... INFO, C <br /> '+ EH 13-24111 16/mi <br /> EH 14-28 ' <br />