Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE"TON AVE., STOCKTON, CA <br /> Telephone (249) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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. 1952 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> cu <br /> Job Address 4 � —_- City Lot Size Im vftLepm <br /> JWi .� <br /> Owner's Name ems' ` Address a +f` Phone. <br /> 11�� t � <br /> Contractor JfOir'�014 0�sf.0 Address License No_ Phone 77i9 r;tO <br /> T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ET DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ +SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINE DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONti - AGRICULTl1RE WELL'� ' OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREV CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom CJ Manteca Dia. of Well Excavation Dia. of Well Casing �. <br /> ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications z *� <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .-Type of Grout w e` ' <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by t <br /> r F- <br /> Repair Work Done {❑ Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50')' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION A1 REPAIR/ADDITIONJ].,DESTRUCTION _ (No septic system permitted if public sewer,is. -� <br /> available within 200 feet.) r <br /> Installation will serve: Residence� 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 A. I Capacity�f/ t00 No. Compartments <br /> PKG. TREATMENT PLT.<]­� " ' 't { Method of Disposal <br /> Distance to nearest: <br /> Well, 70 # :Foundation - Property Line <br /> � ♦tip, <br /> LEACHING LINE i �9 No. & Length of lines f .2, Total length/size <br /> FILTER BED L1 Distance to nearest: kYwell !#Foundation JfS Property Line' 1_1�; <br /> SEEPAGE PITS Depth 115 t Sizer 3. + ' Numher ---A <br /> SUMPS ` ❑ Distance to nearest: I Well &LIFoundation-w.. '0'4_�Property Line - <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that Phave 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 /> tion laws of California:" } 1 <br /> The applicant st call for re red in ctio Complete drawing on reverse s <br /> Signed Title: Date: <br /> -\FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection <br /> ,,..,,❑❑ Date —*0 Final Inspection by Date <br /> V <br /> Additional Comments. � e <br /> ❑ Stk 466-6791 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy - <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 <br /> IPEE AMOUNT DUE MOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.1/8 5) <br /> EH 14-25 <br />