Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 406-6761 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> AppGratian is tweby made to the San Joaquin Local Health District for a permit to construct and/or Install the work heroin described.TMs soollcatbn N <br /> .rude In compktnce wit n Sun Joaquin County Ordinance No.549 for sewage or No. IB62 for well/pump and the Rules and Regulations Of the Sen Joaquin <br /> Local Health D%IriCt. <br /> Job Address /L/�y 7 S��f}LC, City Size_ PM <br /> 0.",Name r M Qr.7 rf <br /> Address phone <br /> C < <br /> ,L.{— 1 <br /> on�rac.la�A�/'�1p( h� PEdtess3s0 Of- License Nosy �/��PMone EQ <br /> TYPE OF WELL/PUTAP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl <br /> DISTANCL' TO NUAEST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTt1RE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ IntWsbtal C5-opens Bottom 0 Manteca Du.of Well Excavation Da.of Well Casing <br /> ❑ Domestic/Private ❑Gravel Pack ❑Tracy Type of Casing Specifications <br /> I1 Pub6c ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ <br /> I I Inipatios _APEVOx. Depth I I Eastern Surface Soul Installed by <br /> Repair work Done ❑ Type of Pump H.P. State Work Done <br /> Wee Destruction ❑ Wall Diameter Sealing Material(top 50'1 <br /> Depth Filler Material IBeiow 50'1 ' <br /> TYPE OF SLPTIC WORK: NEW INSTALLATION I 1 fILPAIR/ADDITION STRUCTION I I INo septic system permitted if public sewer is { <br /> available within 200 feel) <br /> Insta4tion vA serve: R L—t'ommertial_ Other J <br /> Number of kving units: Number of bedrooms �7 <br /> Charn]er of&a to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapaciryLawc-� No. Compartments <br /> PKG.TREATMENT PLT.❑ r -t' L- C O YCre+is- Method of Disposal <br /> Distance to nearest: Well Foundation Property Line T <br /> _ IT D <br /> LEACHING LINE CIL o. 6 Length of lines - Total krngth/size_�� <br /> FILTER BED ❑ Distance to nearest: Wei- Foundation — Property Line <br /> SEEPAGE PITS I I Dplh Siza — Number <br /> SUMPS i.1 Distance to nearest WNI _ Foundation Property Line - <br /> DISPOSAL PONDS ❑ <br /> I haraby certify that 1 M prelarad this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,and e <br /> rubs and reputation,or the San Joaquin Local Health Ddoict. <br /> Hone owner or licensed agent's eignalure cenifres the following:"I certify that in the Performance of the work for.Mich this permit is issued.1 Yap not <br /> ampby any person in such manner as to become wbject to workman's compensation laws of California:'Contractor's hiring or subcontracting signature <br /> cars the fobwing:"i cantly that in the performance of the work for which this permit is Issued,I shall employ portions subject to workman's comlpensa. <br /> ton 1 CaMornta." <br /> The> �n t up a4 r ired pecti ns. Com a drawing verso sl e. <br /> S:gned _�� Title: 7; c ���-� 'f� Uata: L S <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by .- Date LA_� Area <br /> Pu or Grout Inspection by Da:o___ Final Inspection by Date <br /> Additional Comments: — <br /> '.3 Sets 4666181 ❑Lodi 3693621 ❑ Manteca 8Z3 7104 ❑ Tracy 635-BM <br /> tppkcant- plenum an copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Sik., CA 95201 <br /> fEE AMOUNT DUE AMOUNT REMITTEDC�6H RECEIVED BY DATE PERMIT NO. <br /> NFO —1 <br /> se I`z,lazy ". 9 (� -Zry �—/ <br /> +I s <br />