Laserfiche WebLink
APPLICATION FOR PERMIT <br /> :. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephcne (209) 456-Ml <br /> ' `• PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (COmplete in Triplicate) <br /> i; Application is hereby made to the San Joaquin Local Health District for a Permit io construct and/or fnstaif the work herein described. <br /> F' C made in compliance with San Joaquin County Ordinance No.W for sewage or No. T8v for well) um and the Rules and fl �application is <br /> Or <br /> Local Health Districts. /Jy Pump Regulations tai the Son J�aquln <br /> Jab Address r <br /> x; City— Lot Size pM <br /> it Owner's Name -7 Address <br /> t: <br /> Phone, <br /> { F1 <br /> Contractor's Mame r ` <br /> ! ti ' icense No. Phone tf07 \ <br /> f s, TYPE OF WELLlPUMP: NEW WELL ❑ <br /> WELL REPLACEMENT _ DESTRUCTION ❑ <br /> �. PUMP INSTALLATION ❑ SYSTEM rEPAfR 0OTW,__ <br /> DISTANCE TO NEAREST: SEPTIC TANK R ❑ <br /> y — SEWER LINES DISPOSAL FLD. PROP, LINE ` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS <br /> F INTENDED USE TYPE OF WELL PROBLEM ARCA CONSTRUCTION SPECIFICATIONS <br /> i ❑ Industrial ❑ O n Bottom <br /> j !� ❑ Manteca DIa. of Well Excavation _— Ola.of Well Casing ? r <br /> ❑ Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing <br /> ❑ Public ❑Other Specifications <br /> 0 Delta Depth of Grout Seal <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Type of Grout <br /> Suriace Seal Installed by. r <br /> Repair Work Done ❑ Type of Pump H.P._ <br /> Wel!Destruction ❑ Well Diameter c State Work Done <br /> 'Sealing Materiel(top 50') <br /> "- Depth Filler Material(Belcw So') 7� <br /> } TYPE OF SEPTIC WORK; NEW INSTALLATION f] REPAIR/ADDITION ❑ DESTRUCTION to {No se tir.s a <br /> s P Ystem permitted if public sewer is <br /> Instaltation w�i'll'serve: Residence— available within 200 feet.) <br /> • � ence— Commercial ,Other t� <br /> =a Number of fy;gg units: Number of bedrooms _ <br /> � 'CfSulacteraf�:soil'ta a depth of 3 feet: <br /> SEPTIC TANK O —YFe/Mig Water table depth <br /> PKG. TREATMENT PLT.E-1 Capacity__��_.._/ No. Compartments <br /> 'Method of Disposal <br /> pista.Itee to nearest: Well Foundation H' Property Lina <br /> LEACHING LINE ❑ No.& L-ar. th of lines <br /> FILTER BED / g 0t "� <br /> t �`Distance to nearest: Well 4&-r— Foundation a <br /> .�, ..�,� Property Line <br /> SEEPAGE PITS N Depth .Size Number_ <br /> t +: SUMPS ZDistance to nearest: Well_ <br /> DISPOSAL PONDS L7 Foundation . Property Line <br /> I harely cert' that I have re �' <br /> rfl' p pared this a Local Hee end that'work will be done in accordance with San_loaquin county ordinances,state laws,and <br /> rubs and regulations of thu Sart Joaquin Local Health District. <br /> Horne ovmer or licensed agent's signature certifies the following:"I certify that in the performance of the work?or which this permit is issued,I shall not <br /> employ any pertnn in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> cc-V'ffes rho iollowing:"I certify that in the performancG of the work for which this perr..it is Ns-)ed,I shah employ persons subject to workm.'-tn's co_mpense- <br /> tinr,laws of California." <br /> The appiitant must c I far al!requited inspections.Com lets drawing on ra grse side. <br /> t Signed X— �[L <br /> TitlR: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Apptication Accepted by <br /> Date Area <br /> Pit or Grout Inspection by pate w __ Final Inspection by <br /> Date C ! <br /> Additional mmenb: ^_—�4�1�C� fd1 •+i;/'c.- i; _'I f -- !�y <br /> 0 Stk4664MI u Lodi 3633621 C Manteca 7104� / <br /> Applicant. Return all c 1= Tracy 8356385 <br /> copies to: Environmental Health Permit/Services 1601 E. Haaelton Ave., P.O. Box Y003 Stk., CA'9mi <br /> I <br /> FEE AMUUNT DUE i AMDUN7 REM11TEb CK s <br /> INfO CASH RECEIVED BY PATE. PERMIT'ND. <br /> EN 13 24 i9EY.10+971 1 . <br /> 1 EH 14.7C <br /> i <br /> l <br /> I' I <br /> I <br />