Laserfiche WebLink
r. APPLICATION FOR PERMIT r <br /> t <br /> SAN--JOAaUIN LOCAL HEALTH DISTRICT <br /> f .+ c ' <br /> 1601 E`hlAZILTONAVE, STOCKTON, CA 0� 11 f � <br /> Telephone 12691 466-6781 <br /> :{- 'P'ERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) EN 'fS�R�1GE ti <br /> Application is he+eby made to the San Joaquin Local-Health District for a permit to construct and/or install the work��rIF n' cubed. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 11111 11111 /J <br /> ew—Aiv <br /> [�._ Lot Size PMS <br /> Job A1dresse' Q+5 7O <br /> D 0 Phone <br /> OwnerV%Address <br /> ContrAddress _ License No..� �Phone <br /> TYPE OF WELL/PUMP: NEWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 1' \ SYISTEMFREPAIR� OTHER ❑ <br /> 'L DISPOSAL FLD. 1� PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK 4 Y SEWER`LINES1��--- _ T <br /> ` ' PITSISUMPS <br /> FOUNDATION—�-- AGRICULTURE WELL BOTHER"WELD` , - <br /> INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPEGIFICAT10N5 l <br /> ❑ Open Bottom LI Manteca <br /> Dia. of Well Excavations, Dia. of Well Casing <br /> ❑ Industrial Specifications <br /> Type.of Casing <br /> ❑ Domestic/Private [5 Gravel Pack ❑ Tracy * i Type of Grout <br /> ❑ Other ❑ Delta Depth`;of Grout Seal­ 0 <br /> l Public m -- r f w 1 <br /> ' ,..Approx.,Depth l I Eastern Surface Seal Installed by ` <br /> (\ I I kligation. ` H.P. _ _� State Worli`Done s <br /> \ s Repair WorklDon6+, Type-of Pump b1i <br /> Sealing Material Stop 50'1 f r (� <br /> Well f)estruction ❑���-Wekl Diameter ` �� " , <br /> *Depth I. ��'`✓ Filler Material ISeloX 501 <br /> TYPE`OF SEPYIC W. 0: INSTALLATION i"If REPAIFPADDITION l I DESTRUGTION l I (No septic sysf4m permitted it public sewer is <br /> } J available within 200 1eet.1 <br /> l ti} <br /> installation will serve: Residence Coriime�ciai' ``" Other <br /> Number of living units: Number ofEbedr6oms f r Water fable depth �I <br /> Character of soil to a depth of 3 feet: - �...- ,, .. ,_ ,�� ,� . tCpm— <br /> Type/ Capacity— No: partments <br /> SEPTIC TANK ❑ 9 Method of Disposal <br /> PKG. TREATMENT PLT. ❑ property Line <br /> Distance to nearest: Well Foundation i i -17� <br /> Total length/ize <br /> ` LEACHING LINE ❑ No. & Length of lines I +. <br /> Foundation Property:Line <br /> FILTER BED ❑ Distance to nearest: Well . <br /> SEEPAGE PITS I I Depth <br /> Size Number ' <br /> Foundation Property`Line <br /> SUMPS L] Distance to nearest: Well # <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that-1 h par this application and that the work will be done in accordance with San 3oaquin county ordinances, state laws, and <br /> rules and regulatio of the San Joa in Local Health District. I <br /> Home owner or I ensed agent's sign tura certifies the fo11 1 : ­I certify that in the performance of the work for which this permit is issued, I signature <br /> shalt not <br /> employ any pe on in such manner to beco bj�ct tt workafor ch this perm n's compensation aissued,of fI shall employ personslsubj subject t woring or rkman's compensa <br /> certifies the f lowing: "I certif a 'n the pe <br /> tion laws of alifor ' Air <br /> The applicant must c II a quir mplete awing <br /> Title: <br /> Date: <br /> Signed K <br /> FOR DEPARTMENT USE ONLY d <br /> r Date — Area <br /> •-�"� <br /> Application Accepted by � <br /> Date <br /> Final Inspection by a ate �A. <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> O Stk 466-6781 ID Lodi 369-3621 El Manteca 823 7104 11 Tracy 535 6385 <br /> i Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 1009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH `� r <br /> f!�� <br /> INFO <br /> 4910- f7, <br /> +.EH 13-21(REV.I/14!5) <br /> j <br /> ` EH 14-26 + <br /> i ■ - <br />