Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT -� \ f <br /> 1641 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (249) 466-6781 <br /> PERMIT EXPIRES 'I'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 TV'li� "tj�cation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulat oxi'��f.'ttib�San Joaquin <br /> Local Health District. .�` Rt <br /> (� n•�,. <br /> Job Address T262C1 ­FA,5T .FOLIA City E51AL-19/1/ Lot Size -1-0 462E PM <br /> Owner's NameI9/�CTC!_!../`'ICy/1! Addres <br /> Contractore sZQSse Nv.c Phone 6 — <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT V— DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑_ <br /> `DISTANCE TD NEAREST: SEPTIC TANK __ SEWER LINES DISPOSAL FLD.ZQ( PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> .Domestic/Private -PLGravel Pack ❑ Tracy Type of Casing PV—(— ' 160 SC#• Specifications <br /> [-I Public f 3 Other ❑ Delta Depth of Grout Seal _c��% Type of Grout-92W <br /> I I tfrigation IA6OApprox. Depth Eastern Surface Seal Installed by <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 11 REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer-is-6, <br /> available within 200 feet.) <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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 �(} <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of fines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> IIS <br /> SEEPAGE PITS I I Depth Size _ Number <br />"""'�'UMP�-' ❑ Distance to nearest: eil""""�Fotind'ationro'"erf'"`Line 4an <br /> DISPOSAL PONDS ❑I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state law <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." • <br /> The applica ust II f r all re ed inspections. Complete drawing on r Me slp. <br /> Signed X Title: bate: <br /> FO EPARTMENT USE ONLY r f <br /> Application Accepted by s' , Date __ Area ! <br /> Pit or<S <br /> nspection by date Fina Inspection by f E% Datei'/F/ .� <br /> Additional Comments; <br /> / Gys" .tom Ale <br /> �f.,. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 /~'' <br /> Applicant- Return all copies to: Environmentat Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 0IR <br /> FEE <br /> INFO AMOUNT DUE AMOUN REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> +.EH 13.24(REV.I/a 51 7/ <br /> EH 14-25 "//rrt� 1toE? <br />