Laserfiche WebLink
1 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> r 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 /> 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, <br /> I Job Address _�•^_ .-... ASO S t eY lLr+ _ City_ r Lot Size - PM -- <br /> i <br /> Owner's Name p ry it X Address f�' rs 3 Ei0 ��! Rd _ Phoneme'' <br /> �1�� _.T _.._ <br /> Contractors �r A� 1l 5v11r' Address a �L V S d"7 License No.Woo""I Phone Ag-?­y'ut*" <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION•'❑-- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR CJ OTHER Cl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ._. DISPOSAL FLO. PROP. LINE"=_. <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation __._ Dia. of Well Casing <br /> nt <br /> ❑ DorrkesticlPrivate ❑ Gravel Pack Tracy Type of Casing Specifications <br /> M Public P. Other n Delta Depth of Grout Seal ,_ Type of Grout <br /> I I Irrigation —Approx. Depth l 1 Eastern Surface Seal Installed by- ------ <br /> Repair Work Done ❑ Type of Pump H.P. _....__ State Work Done_.._...._ <br /> t Weil Destruction L Well Diameter _ Sealing Material (top 501 <br /> Depth _ Filler Material )Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION DESTRUCTION I I iNo septic systern permitted if public sewer is 1LY <br /> - <br /> " available within 206 feet.) <br /> Installation will serve: Residence ` Com'ercial_ Other <br /> Number of.living units: L _ Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: J-0.4w r _Water table depth O <br /> { SEPTIC TANK 71 Type:Mfg Capacity_-----­__..__­ No- Compartments <br /> PKG. TREATMENT PLT,0 Method of Disposal <br /> Distance to nearest: Well Foundation_ Property Line <br /> t LEACHING LINE Rv No,& Length of lines !Oa' Total length/size Avg' <br /> FILTER BED tJ Distance to nearest: Well l O C Foundation_4-0 — Property Line 10 <br /> SEEPAGE PITS I I Depth Size _............._-_..._ Number <br /> SUMPS L: Distance to nearest: Well _-� Foundation Property Line_ <br /> I DISPOSAL PONDS Ci <br /> i <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, an <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, I sha41 not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting-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 California." <br /> The applicant mus call for all required inspections. Complete drawing on reverse side_ <br /> Signed Title: Date: 41—/3-90 <br /> WFOR DEPARTMENT USE ONLY <br /> Application Accepted byIwoData q I D Area <br /> r Pit or Grout Inspection by _. Date Final Inspection by (¢ Datec2 <br /> Additional Comments: �!J <br /> i] Stk 466-6781 CI Lodi 369-3621 ❑ Manteca 823.7164 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2069, Stk., CA 95261 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> RECEIVED BY DATE PERMIT NO. <br /> f INFO <br /> EH 14-M R <br />