Laserfiche WebLink
` APPLICATION FOR PERMIT <br /> Orb SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 2 tiJ`•¢J"'o. I Telephone (209) 466-6781 <br /> Z �LAVkAf s PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> T — (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)oaquin 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 Atldress -�' i9A' City Mt Size PM <br /> r Tve�oc+C <br /> Owner's Name .�, ?ddress (/( , �;F l�J Phone 61a 4?— / <br /> _��� -.� _ <br /> Contractor •Atltlress License No. Phone <br /> TYPE OF WELL/PUMP: WELIf5v WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 1ei — _(9_PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ �pz <br /> r DISTANCE TO NEAREST! SEPTIC TANK . SEWER LINES DISPOSAL FLD. PROP. LINE1. <br /> ie�vpnfi <br /> FOUNDATION 1j:2— AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE @TYPE OF WELL PROBLEM F,GREA CONSTRUCTION SPECIFICATIONS <br /> ]Industrial 0 Open Bottom ❑ Mantbca.; Dia. of Well Excavation y Dia. of Well Casing �f v <br /> ❑ Domestic/Private VGraval Peck _ ❑ Tracy,I Type of Casing �T�wf'y�� Specifications <br /> 11 Public fl Other 1 n Dp Za„ Depth of Grout Seal �l/U Tyge of Grout <br /> T 1 1 Irrigation =Approx.�epth" I,�Eestem-' S Surf)c Seal Installed by <br /> �. r <br /> Repair Work Done ❑ Type of PumpD. <br /> �_.,.,z H! 7 State Work Done <br /> { r —j ^. <br /> Well Destruction .❑ Well biemet92'� 'Aealfng Material [top 501 (1 <br /> �. Depth - --•--Z • 'r �Filler Material (Below,50') AN <br /> TYPE OF SEPTIC WORK: :NEW INSTALLATION I1 REPAIR/ADDtT10N I I DESTRUCTION I I (No septic system permitted it public sewer is O <br /> y r '•,4.. \, available within 200.feet.) <br /> .. .—Anstallation_willsetva;, R desige4pe�y C�rppyreial_�4 Other <br /> rr' Number of living,unib:p Number of rooms <br /> Character of s�l-to a depth of 3 Teel: ' % Water table depth <br /> SEPTIC TANK ❑, TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O �-,ti Method of Disposal <br /> Ir <br /> Distance to nearest: Well Foundation �•, Property.Line <br /> 5 <br /> LEACHING LINE ❑i No. & Length of lines atal length/size <br /> FILTER BED ❑j Distance to nearest: Well Foundation Property Line <br /> t <br /> ' SEEPAGE PITS Ila Depth Size Number <br /> SUMPS La Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑: <br /> I hereby certify that 1 have�rspared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rubs and regulations of the t San Joaquin Local Health District. <br /> r <br /> Home owner m 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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I caitifv 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.a'�".{A <br /> The applicant %lequir ns. complete drawing on reverse side. <br /> T Signed x �V Title: __-/ � L9'''!s Dater �n�—I S/f <br /> FOR DEPARTMENT USE ONLY redr'awlr�.� <br /> Application Accepted by ry Date e _C _y_ <br /> ®6 <br /> Pit Gro nspection by Date L_ G' �" Final Inspection by Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 • O(Lodi ,369-3621 ❑ Manteca 623-7104 ❑ Tracy 8395-6395 <br /> yApplicant - Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 <br /> R. <br /> FEEFO AMOUNT.DUE.. AMOUNT REMITTED CASH RECEIVED 9y DATE PERMIT NO, <br /> _ INq <br /> ..EH <br /> EH tr X <br /> I <br />