Laserfiche WebLink
. 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) <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."rir� �" / <br /> Job Address �l�J -+ U /�� City-! A,rLot Si <br /> Owner's Namer _ �,t/ /fes x�✓ `d /A�d�dress [.S�/�. //��/VGG�//Z�Gt(c�jLf: Phone <br /> Contractor ✓Ql. !�/// z �Address iE:P.IT�i£.:x� e.�rq License No.J6/337 hone- --W4 7 <br /> TYPE OF WELL/PUMP: NEW WELL _ WELL REPLACEMENT ❑ DESTRUCTION ❑ V\ <br /> PUMP INSTALLATION R SYSTEM REPAIR ❑ OTHER ❑ ) <br /> DISTANCE TO NEAREST: SEPTIC TANK "'"'Z.J-� SEWER LINES - Z l DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI ATI S <br /> �L1 Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C1 Domestic/Private IXGravel Pack O Trac Type of Casing JlT�� ` <br /> Y YP 9 SpecificationsT <br /> 11 Public X Othe 1-I Delta Depth of Grout Seal �J Type of Grouf <br /> I I Irrigation 1_&Approx. Depth I I Eastern hIrface Seal Installed by dlpgf / C•� - <br /> Repair Work Done 0 Type of Pump _J_i4V H.P. State Work Done <br /> Well Destruction Ll Well Diameter _ Sealing Material (top 50') <br /> Depth Filler Material (Below 509 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I SEPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is <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 I.1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. (_I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 1.1 No. & Length of lines .__ Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth —. Size____ Number <br /> SUMPS L Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 11 <br /> I hereby certify that I 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 Diktrict. <br /> Home owner or licensed agent's signature cenifies 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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in th performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." /� <br /> The applicant m St or all re d in ffact(o omplete drawing on rove side. ) pp <br /> Signed X � i Title:-/� i/�G7Y ` Date:: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byz Date [� Q <br /> - / ����Q Area <br /> Pit or Grout Inspection by` �/�r �7- Date ��/�,� Final Inspection by <br /> `,A Date <br /> Additional Comments: ./K�l 7�/e - k rie,06 1 PLV / '7 MIlet W 88 Oto ,L�Gt�Ey2T_ <br /> 0 Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> ♦.EM 13.241REV.1/95) /1 <br /> EH 14.38 - ✓ :l '/ �/ �J� <br />