Laserfiche WebLink
77 <br /> - Al 7 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH 'DISTRICT <br /> 1 <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 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 /> 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. j]� / <br /> Job Address Y+ y' eCity Lot Size/�6 X 1 DQ PM <br /> Owner's Name Flo yeewL e 5-5 Address Phone <br /> Contractor Tf.4L2, License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW LL ❑ WELL REPLACEMENT C1DESTRUCTION ❑ <br /> PUMP INSTALLATIO ❑ }�.C4%**rLSYSTEMi R�AIRfQjt& ,h� Aj OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLD. PROP. LINE <br /> .r FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR BLEM AR CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ n Dia- of Well Excavation Dia. of Well Casing d <br /> ❑ Domestic/Private "'"❑ Gravel-Pack r y Type of Casing— -»-� ....�.� _ r ..Specifications <br /> Fl Public ( ] Other Cl Delt Depth of Grout Seal Type of Grout _ <br /> 11 Irrigation _Approx. Depth 1 1.Easte n Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of-Pump H.P. "` State Work Done O <br /> Well Destruction p Well Diameter ealing Materia! {top 501: _ t <br /> Depth + Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.� REPA1R/ADDITION 1.1 DESTRUCTION' �.INo septic system permitted if public sewer is <br /> f f 10 --- - 0 . — available within 200 feet.) . ) <br /> Installation will serve: Residence— Commercial_ Other <br /> r �fNumber of living units: Number of bedrooms ' 1 <br /> Character of soil to a depth of 3 feet: ` Water table depth I <br /> SEPTIC TANK L1Type/Mfg ' "' "'�" {'"` '"'""Capacity No`Compartments <br /> PKG. TREATMENT PLT. ❑ W � Method of Disposal <br /> Distance to nearest: Well ,Foundation Property Line I <br /> LEACHING LINED ❑ No. & Length of lines 1 .1 Total length/size( I <br /> I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line t <br /> SEEPAGE PITS t I 1 Depth Size t-A ;►t 4 t Number <br /> SUMPS0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS I-) # k <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, I shall not <br /> employ any person in such manner as to become subject to workman's compensaiio?i laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:5'1 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." f !ta <br /> { t <br /> The cant st call for all required ins ctions. Complete drawing on reverse side. Y f <br /> Sig ed Title: — _ Date: M4c r /_13 YJT 7 <br /> FOR DEPARTM NT,USE ONLY;`h t 4V' <br /> Application Accepted by y Date ~ Area_ 0 <br /> Pit or Grout Inspection.by„ Da Fina! Inspection by Date's <br /> Additional Comments: <br /> ' e ti <br /> ❑ 5tk 466-6781 }❑ Lodi 369-3621 z IJ Manteca 823 7104 U Tracy 835 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'No. <br /> INFO ASH <br /> + EH 13-24 IREV.1/H 5) <br /> EH 14-26 <br />