Laserfiche WebLink
I`ll <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I Telephone (209) 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 and/or install the work herein described. This application is <br /> I made in compliance with San Joaquin 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. 7 ��] //} .� /J�,�� 0 J' <br /> Job Address&)9-330 �G.YXILI-k2y/dW/W/' Ci Lot Siza.Q� PM <br /> Owner's Na Address Phone <br /> Contrac Address License No. Phone 40 <br /> TYPE OF WELL/PUMPr,. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ _ <br /> I I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump HIP^ 'I -- - --State Work-Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') 'f <br /> Depth I Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION - EP ADD1710 _ DESTRUCTION I I (No septic system.permitted it public sewer is <br /> �1nc11". available within 200 feet.) - t <br /> Installation will serve: Resi esCommercial Ocher <br /> Number of Irving units: 71 Number r m \ <br /> Character of soil to a depth of 3 feet:--I� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> ✓ Distance to nearest: Well Foundation Property Line <br /> it <br /> LEACHING LINE �? /�p`'��7J6. & Length:of lines T�tal length/size <br /> FILTER BED " ' ❑ Distance to nearest: well .'S a Foundation_/_4 Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well "l Foundation ��'Property Line <br /> DISPOSAL PONDS ❑ .,� <br /> I hereby certify 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 District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify 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 ifomia." Date- <br /> FOR <br /> The applicant u call for r uire inspections. Complete drawing on raverrr/555t���ssa ��SignedX tl ^ ..Tide: ' Vl �� -DEPARTMENT USE ONLY - <br /> C <br /> Application Accepted by Date"' i�J���� '�� Area Z 3 <br /> LEII <br /> uLinspection by Date Final inspection by�J{�'�\a-=�. Date <br /> Comments: <br /> 66-6781 ❑ Lodi 3693621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> • Return all copies to: Environmental Health Permit/Servi 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DU (AMODU1NT R,.E,M.IETTTEED Clll SH RECEIVED BY ,DATE PERMIT NO. <br /> ''1.+rU l q I <br />