Laserfiche WebLink
x - <br /> - e <br /> APPLICATION FOR PERMIT <br /> 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 /> Job Address — ta 2Cl s (Z1W0'4) City / ,VT4 C Lot Size 3PM <br /> Owner's Name Address _ rer,2 35/ �- U/1f/p riJ _ Phone <br /> Contractor's Namefi2a4 License No. C� Phone <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 W <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 ❑ Gravel,Pack, ❑ Tracy Type of Casing Specifications <br /> ❑ Public D Qther' .' ❑ Delta Depth of Grout Seal Type of Grout <br /> `❑ Irrigation �Approx. Depth ❑ Easter'r-I­`___—Surface Seal'16italled <br /> Repair Work Done ❑ Type of Pump s H.P. State Work Done 4 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth I Filler Material IBelow 501 <br /> }TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONX DESTRUCTION ❑'(No septic system permitted if public sewer is <br /> - available within 200 feet.) <br /> '�� �� �Cor�tmercial_ Other <br /> Installation will servei Residence <br /> Number of living units: Number of bedrooms. <br /> Character of soil to a depth of 3 feet: 6,9ADy Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.,,0_ Method of Disposal <br /> \ Distance to nearest: Well Foundation Property Line <br /> -i HfNG LINE' ; C1 No. &'Length of line sl� FT Total length/size <br /> FILTER BED Distance to nearest: Well Foundation 7 Property Line or <br /> SEEPAGE PITS Q Depth - _' Size Number <br /> SUMPS ❑ Distance.to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ��-- <br /> hereby certify that-4 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 I <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 applicant must call far Il,re 'red inspections. Complete drawing-on reverse side: <br /> i �� /� is <br /> Signed Title:, i � w Date: /Ci / `Jljl <br /> FOR DEPARTMENT USE ONLY <br /> f i'- <br /> Application Accepted by - Date - -1977--r-1- Area <br /> Pit or Grout fnspectioD._by___ I Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104i 11Tracy 835-6385 <br /> Applicant'-Return all copies to:-Environmental-Health-Permit/Services-1601 fE.--Hazalton-A$e.,--P.O.-Box2009, Stk.,-CA 955201 FEE <br /> -� <br /> INFO JAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �+ PEfR�MIT'NO. <br /> + EH 1324 4REV.10/83) r-i--`•a V1 rA�y j �7,___({,�—B I" �� _ J <br /> EH 14-28 i✓ (/°Y f ..11 <br />