Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAO.UINFLOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-67.81 r q n . <br /> PERMIT EXPIRES:1 YEAR.FROM:DATE ISSUED , <br /> _. ,.;.�.::� '.���-cr�:^; ��xf�+ .: ; :.r :4:�'^:�'►,:. (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 forwelllpump and the Rules and"Regulations of the San Joaiquin, <br /> Local Health District.t f 4 :r + x�,Y <br /> IV <br /> Job Address Size PM <br /> City <br /> � � � � _ / ... -.� .. �.._. -. --y . <br /> -Phone <br /> Owner's Name cess ; s "' + S I` <br /> ~ cense No. Phone <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: NE4V WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Ll SYSTEM REPAIR ❑ OTHER ❑ <br /> B DISPOSAL FLD. PROP. LINE. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL: OTHER.WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom- • ❑ Manteca "Dia: of Well Excavation <br /> T e of Casio �-' Specifications <br /> ❑ Domestic/Private fl Gravel Pack ❑ Tracy yYp g a, <br /> 11 Public Ll Other ❑ Delta Depth of Grout SealType of Grout (� <br /> ❑ Irrigation --L-Approx. Depth ❑ Eastern Surface Seal Installed by" <br /> H p State Work.DonO <br /> Repair Work Done EJType of Pump ,; -,- � 41-11 <br /> Well Destruction E] Well Diameter Sealing Material {top 50'} I <br /> Depth Filler Material (Below ,) <br /> perrn <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,ElREPAIR/REPAIR/ADDITION DESTRUCT,{ION O ( o setcaNailabie�witiii e20D fi etitted if public sewer is " <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 i <br /> ,F Capacity No. Compartments l� <br /> SEPTIC TANK E3 _Type/Mfg ` <br /> Method of Dispospl <br /> PKC. TREATMENT PLT. 11M c <br /> .w } <br /> Distance to nearest:" Well Foundation .— Property Line <br /> LEACHING LINE. X.No. & Length of lines ! Total length/size 3RQ <br /> FILTER BED ❑ " Distance to nearest: Well " —Foundation Property Line <br /> t <br /> SEEPAGE PITS ❑ Depth t Size Number <br /> SUMPS Distance to nearest: Well rFound'ation _ Property.Line <br /> DISPOSAL PONDS ❑ o.— <br /> =4 i <br /> I hereby certify that! have prepared this application and that the work will be done in accar once with"San;Joaquin'county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. t <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, 1 shall not <br /> employ any person in such manner as to.become subject to workman's compensation laws of-California:"..Contractors-hiring or sub contracting signature <br /> certifies the following:"I certify that in the performance of the work for <br /> which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws"of California." I ; <br /> The applicant must call for all required ins ions. Complete dra ing'on revers side. <br /> i <br /> Title: ! ?Date: _ <br /> SignedLei—, „ <br /> FOR DEPARTMENT USE ONLY <br /> s Date [ U­/ ,.;Area <br /> Application Accepted by Wyk, tti ~ t � , <br /> D” <br /> ,Pit or Grout Inspection by Date Final inspection by <br /> !Additional Comments: <br /> QI6,Stk 4B6 6784 ❑ Lodi 3W3621 ❑ Manteca` 823-7104«- El Tracy.. 835-6385 ` -`•:__ E - M-- 9i * <br /> Applicant- Return all copies to: Environmental Health Permit/Service`s 1601 E. Hazelton Ave.,:P.O Box 2009, Stk., CA 95201 <br /> i <br /> FEE CK RECEIVED BY DATE <br /> INFO PERMIT`NO. <br /> AMOUNT DUE _ AMOUNT REMITTED ! CASH <br /> -•�— /� 5 >� <br /> f '�( <br /> 24 <br /> EH 13-241REV.101831 " A j � 4 �`I'g <br /> EH 14-28 I �, <br />