Laserfiche WebLink
'r <br /> APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete 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. <br /> Af y % I <br /> Job Address V `� R K City 0 r Lot Size 7�X 1-7 S_�PM <br /> Owner's Name Do N N A V N ITR0 I4'ddress 0 �.� !"l V �1 OPhone <br /> 4 Contractor's Name License No _ Phone <br /> l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom' C1Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack 'Cl Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done d <br /> Well Destruction ❑ Well Diameter Sealing Material(top 501 <br /> Depth t Filler Material !Below 50'1, `` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/A DI I N ❑ DESTRUCTION ❑ (No septic system permitted"if public sewer is <br /> 0 feet) <br /> available within 20 {� <br /> i -C4-, t�'���1�,.�.� �,. <br /> Installation will serve: Residence— <br /> Commercial-,- =` Other <br /> Number of living units: Number-of-bedrooms . <br /> Character of soil to a depth of 3 feet! Water table depth (� <br /> SEPTIC TANK Type/Mfg yvY Capa,! PZAO A<-�-No. Compartments <br /> t PKG. TREATMENT PLT. ❑ , / / Method of Disp9sal <br /> Distance to nearest: Well _" _ Foundation f Property Line <br /> LEACHING LINE No. & Length of linesTo�al length/size <br /> l <br /> FILTER BED 1:1 Distance to nearest: Well _ Foundation__. 1— _ Property Line f <br /> SEEPAGE PITS ❑ Depth I Size + 2 Number " <br /> SUMPS _ T ❑ 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 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 /> II employ a rson in such ma s to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t e IlowA' cert!,,Znth in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensation laws of alit The appl a musall a ui d in pe ions. Complete drawing re a se side. <br /> I- \ii�q <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by pate Area Q <br /> F + ' <br /> Pit or Grout Inspection by t Date Final Inspection br2y Date r <br /> ! Additional Comments: <br /> x D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8366-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE' AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO CAS <br /> fH h �Q <br /> + EH 73-24 iREV. 10/83) L�s `j �4- <br /> I EH 74-28 l <br />