Laserfiche WebLink
' 003494 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT { �" <br /> 4 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> l <br /> (Complete in Triplicate)p <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.649 for sewage or No.1882 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address r ,� 1 r', Cm, 1� � .: %y Lot Size .! 7• �r r-'sr <br /> PM <br /> Owner's Name Address f Phone <br /> � . tiContractors Name Phone t�jltn� • nseNo- <br /> TYPE Z ` <br /> OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT [3 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP LINE <br /> j. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ lndustriai <br /> P ❑ Open Bottom ❑ Mantaca Dia.of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> --Approx. Doom ❑ Eastern Surface Seal Installed by � <br /> Repair Work Done ❑ Type of Pump H.P State Work Done f <br /> r <br /> Well Destruction ❑ Well Diameter Sealing Material{top 501 C, <br /> . Depth Flier Material (Below 6T) <br /> TYPE OF SEPTIC WORK NEW INSTALLATION C1 REPAIR/ADDITION ❑ DESTRUCTION❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_Lf Commercial— Other ' <br /> Number of living units: Number of bedrooms <br /> Character of soil to a dep of 3 feet; r <br /> " '- 'ij .. ' Water table depth <br /> SEPTIC TANK El Type/Mfg 0 Ca c <br /> pa ity—Z v Ca, No,i;Compartments <br /> PKG. TREATMENT PLT ❑ � ��� t Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> ). �. <br /> € <br /> LEACHING LINE ❑ No.8 Length of lines- Total length/size c <br /> FiLTER BED ❑ Distance to nearest: Well ` ' ':/ d� fi <br /> I �-- -Foundatbn 1 Property Line <br /> SEEPAGE PITS I%-• Depth Number <br /> SUMPS ❑ Distance to nearest We41 Foundation Property Line <br /> DISPOSAL PONOS ❑ <br /> I hereby certify that!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 District. <br /> Hume owner or-licansed agent'sL <br /> e following; "I certify that in the performance of the work for which this permit is issued, I shall not <br /> emploY y person in such mannect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following;"1 certify te of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant fo Ilate dr wing on reverse skis, <br /> signed 107) <br /> : Date. <br /> OR PARTMENT USE ONLY VApplication Accepted by Date -�51Area p� <br /> lt or rout Inspection by ateS!�5dA721JRnal Inspection by yADate S� <br /> Additional Comments: <br /> ❑ Stk 466-9781 Lodi. 369-Ml 0 Manteca 823-7104 ❑ Tracy 835-8385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEF CASH <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECENED BY DATE PEiMn-No. <br /> 'EH 1 tAsv-10/w) �-{S d 3 <br />