Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telepli 1209) 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 ani install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance Na 509 for sewage or No. 1862 for well/pump and the Rules and Regularfons of Ina San Joaquin <br /> Local Health Dist�rictt..� h ` . 1� <br /> Job Addross J(aa'tlJ''v11 4E� /1[l.(. �+^^1 City Lot Size PM <br /> Owner's Name�j]V 1�1' f Si� ) Address <br /> ,�_ .r , // Phone <br /> � k 7 _ <br /> Contract a�7�l?1.1 D 1 I Address ax; � q l adl_icense No./4 Phone <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 FUD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications <br /> fl Public ❑Other ❑ Della Depth of Grout Seal Type of Grout_ <br /> I I Irngation _Approx. Depth I I Eastern Surface Sail Installed by _ <br /> Repair Wort Done ❑ Type of Pump M.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Maronal IBelow 50'1 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ESTRUCTION I I (No septic system 1 <br /> p Y permitted ii public sewer is <br /> available within 200 feet.) - Q <br /> Installation will serve: Residence Lf medial_�iptner _ <br /> Number of living units: �_ Number of b Brooms •� <br /> Cheractef of soil to a depth of 3 feel: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments rr� <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE IrT'- 6 Length of linos _ Total langthhi:e � <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS I%L—Depth Size rr��unto, <br /> SUMPS LI Distance to nearest Well oundatiom..L„7� Propmry Line A if <br /> DISPOSAL PONDS ❑ <br /> I heroby cenlfy 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 D13trlct. - <br /> Home owner w licensed agent's signature"mites the following:"I certify that in the pertormance of the work for which this permit is issued,I shall not <br /> omploy any arson m such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following;,­LcIrnsfy that m theperformance of the work for which this permit is issued,I shall employ Persons subject to workman's compensa <br /> tion Califon la." <br /> The apdican n It for all r uir ins ions. o rawingo�`r—av—er5 side. <br /> itle: <br /> Sig <br /> Date: <br /> /FOR RTMENT USE ONLY <br /> Application Accepted by / _ Date //— At" <br /> Pit or Grout Inspection by Date Final Inspection by +r rtdl. 1 —'..i/�1 Date <br /> Additional Comments: ✓ 9'r�. d'.y P.Zic A/ <br /> ❑Sit, 4666781 ❑ Lodi 3693621 ❑ Manteca 8237100 ❑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 AMOUNT DUE AMOUNT gEMITTED CK HECEtVED BY DATE PERMIT'NO. <br /> Nf0 CASH <br /> . FH 69 fAEY.11.1, <br /> FH I..a, <br />