Laserfiche WebLink
Y s . <br /> APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I� (Complete in Triplicate) <br /> Application is hereby made to the San Jbaquin 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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> ��eC> <br /> K OL I a� Y City It f 1� Lot Size PM <br />! Job Address _ <br /> Phone <br /> L <br /> Owner's Name L >_ <br /> �f � i.4 JA��rr�c.r• L�L.��p`o8� <br /> �j,� �I V f Address A License No. 17.ifZ Pho <br /> Contractor A <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f <br /> 1 N� 7 ° ° .-� DISPOSAL FLD. PROP. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINfSr^"� <br /> FOUNDATION. AGRICULTURE WELL ` OTHER WELL (SUMPS <br /> PROBLEM AREA CONSTRUCTION SPECIFICATI <br /> INTENDED USE TYPE 01';WELL Dia. of Well Casing <br /> ❑ Industrial 0 Open Bottom .�.❑-Manteca Dia. of Well"Excava .1, <br /> # Specifications . i # T Aw W+ <br /> ❑ Domestic,/Private, 4. Ll Gravel Pack ❑ Trac y Type o 3 Type of Grout <br /> Other' Ll epth of Grout Seal r # <br /> l�Public Delta 1- .. ..-....�. , <br /> "i`l I'.rngation »� =.-aphrox. Depth ern Surface Seal installed by a r <br /> na L.•v,"' : State Worli Done --- <br /> p <br /> 6 ` _ Repair Work Done ❑ T _ p f 'P.. <br /> T- S'ealin Material (top 50'1 <br /> 'g '""Well �- ion ❑ Well Diameter a, i ,; g - _ <br /> Depth,._�-« M Filler Material (Below 50'1 N <br /> sf ..... ..- <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION'iI" REPAIR/ADDITION DESTRUCTION l I (No sep'ailable within 200 feetit�ed if public sewer is <br /> J <br /> Installation will serve: Residence_ Commercial Other <br /> . Number of living units: Number of bedrooms _ <br /> Gharacter,of soil.to a depth of 3'feet: ru ' Water table depth <br /> t ! a a ity��� No. Compartments <br /> --* SEPTIC PANIC r f❑ Type/Mfg <br /> � Method of Disposal <br /> PKG. TREATMENTP,LT.'❑ _ <br /> --------'-Distance to nearest: - Well Foundation Property Line l� <br /> :Zidt"_ length/size <br /> leng <br /> LEACHING LINE ❑ No. & Length of tines Tota ! <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line / <br /> N t <br /> SEEW PITS t4 Depth Size Number ' <br /> SUMPS L] Distance to nearest: Well Foundation Property Line ` <br /> L PONDS El <br /> hereby certify that I have prepared this apoication and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued; I shalt 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 4. workman's compensa- <br /> tion laws of California." I <br /> The applicant ust call for quired inspections. Complete drawing onreverseside. G <br /> ��• r Title: Date: /rl4 • 4 <br /> Signed X_ � A3_ <br /> FOR DEPARTMENT US ONLY L <br /> Application Accepted by Date 6� Area <br /> Pit or Grout Inspection by ` <br /> Date a Fin inspection by <br /> OiJ 6 <br /> Additional Comments: [,0­0 'Date . . <br /> k �3 Ei Ar7) ?��S <br /> LlStk 466-6781 13 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copies to: Enaironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., C 95201Vill, <br /> ' <br /> r <br /> Ii FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT:0] <br /> Y INFO � y� 414+ EH 13-24(REV.i/851 �a 7S1 ��^ <br /> ' EH 14-2a llf , <br />