Laserfiche WebLink
r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,,,.. , <br /> (Complete in,Triplicate) F <br /> }, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 /> GcJL�Job Address City. Lot Size PM <br /> Owner's Name ' Address =lsJ S [ w �J�,� z i.G 1 <br /> hone <br /> Contract Address_.RO -6&-x2(, Z License No. ZVZZ(, Phone 3G.V 1Q<;— <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 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> —EI—Domestic/Private—El Gravel-Pack..—._-__9-Tracy ---Type•of-Gasing:��� --Specifications" <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout,Seal Type of Grout <br /> ❑ Irrigation �4pprox: Depth ❑,Eastern .i`�.5urfece Seal�lnstalle'd-by <br /> 4 "Repair Work`0"one❑—Type of-pump T r'H.P, -.L'—- State Work bone <br /> ' <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'} <br /> " <br /> Depth I er Material /Below 50'} _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPA/ DDITION E DESTRUCTION(❑ (No,septic system permitted if public sewer is <br /> I' 1 � .-­,� 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 T No- Compartments y. <br /> I PKG. TREATMENT PLT. ❑ r Method of Disposal ` <br /> Distance to nearest: Well Foundation--`I Property Line � Y <br /> 4 i <br /> LEACHING LINE No. & Length of lines _ t Total length/size O/X.7 G <br /> FILTER BED ❑ Distance to nearest: - Well i6_0' Foundation I �Q _ Property Lin oS <br /> SEEPAGE PITS ❑ DepthSize's Number <br /> , <br /> SUMPS ❑ Distance to nearest: Well ,/Foundation Property'Lilrie <br /> DISPOSAL PONDS ❑ I}, <br /> ! hereby certify that I have prepared'this,application-and that-the-work-will'be done.in:accordance-with-San-Joaquin.-county-ortliriances, state laws, and <br /> rules and regulations of the San Joaquin' Local Health District. -oi 'iIA <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 tojbecome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature y <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." C3' a <br /> The applicant st call for al qui r d inspections. Complete drawing on,yeverse 1de: <br /> Signed �. Title: <br /> d _- ' _.. <br /> ��. --�-�--- '. Date: (O <br /> 67 <br /> FO- RTMENT SE{ONLY <br /> Application Accepted byDate Area <br /> 1- Y <br /> Pit or Grout Inspection by Date Final Inspection by Q9jDate <br /> Additional Comments: 41 a <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 11 FEE INFO AMOUNT DUE _ AMOUNT REMITTED '. CASH RECEIVED BY' DATE PERMIT ND. <br /> -+ EH 13-24(REV,7 <br /> EH 14-26 / �♦f� g'" u 10'�� <br /> L <br /> I <br />