Laserfiche WebLink
APPLICATION FOR PERMIT <br /> k' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 46676781 <br /> PERMIT EXPIRES I 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 /> Job Address e City Lot Size PM <br /> Owner's !Name Address �-Q _~ Phone <br /> Cohtractor's.NameL ► - License No. r Phone <br /> TYPE AF WELL_/PUMP: ; �+ ANEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑- <br /> ,PUMP INSTALLATION ❑ SYSTEM,REPAIRs❑ OTHER ❑ <br /> DlSTANCE.T'O NEAREST: SEPTIC TANK SEWER LINES DISP�OSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 44 r-1 i'�INTENDED USEI�Js 1,TYPE OF WELL PROBLEM AREA- CONSTRUCTION-SPECIFICATIONS—­ <br /> LJ <br /> ONSTRUCTION-SPECIFICATIONS=­❑ Industrial•* r»'a p-Open;Bottom " ❑ Manteca: , Dia. of Well Excavafion'io Dia. of Well Casing <br /> ❑ Domestic/Private ❑e�G?avel Pack- 'C -E] Tracy Typebf Casing- Specifications r <br /> ❑ Public_. ❑ Others ❑ Delta Depth of Grout'Sea) -- Type of Grout <br /> ! ❑ Irrigation ---Approx. Depth, ❑ Eastern- --Surface Sea'-Installed by <br /> Repair Work Done ❑ Type of Pumps H.P. l State Work Done <br /> Well Destruction ❑ Well Diameter `� - Sealing Material itop 50') <br /> Depth_ Filler Material (Below 50'1 �j <br /> TYPE OF SEPTIC WORK: NEW INSTALL.ATIONVA'-REPAIR/ADDITION ElDESTRUCTION LJ (No septic system permitted if public sewer is <br /> available within 200 feet.) W <br /> Installation will serve: Residence Commercial .Other <br /> i r <br /> I 'hlumber of living units: Number of be r ms _ ._--_. <br /> A <br /> Character of soil to a depth of 3 feet: _Water,table depth , <br /> SEPTIC TANK ❑ Type/Mfg Capacity- (�C3t? ` ' \No. Compartments <br /> PKG. TREATMENT PLT. D 4 <br /> i Method-:of 0s os_al L.l <br /> Distance to nearest: Well , y Foundation /.___.:.! �. <br /> "�' Property-Line <br /> ` LEACHING LINE No. & Length of lines —1-Total length/size, <br /> FILTER BED ❑ Distance to nearest' ! ,Wel!'?so Foundation\ Property Line '' <br /> i0,3 <br /> i SEEPAGE PITS Depth Size I \Number i <br /> ... _ SUMPS_ - EDDistance to nearest: Well 160 Foundation /O 00*• Property Line' <br /> DISPOSAL PONDS ❑ <br /> k 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 compensation laws of California."Contractor's hiring or sub-contracting signature <br /> i certifies the following: 'I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call f r all re dins ons.'Complete drawing on reverse side. t ` <br /> Signed X Title: r Date: <br /> FOR DEPARTM NT USE ONLY <br /> Application Accepted by Date / u Arre�a�,¢�`� i <br /> or Grout Inspection by t �/ r Date �� z Final Inspection by 1L9:d!0 pate b�A 3 � <br /> Additional Comments: _- „,,,• <br /> ❑ Stk 468.6781--- ❑ L•odi-^-369=3621----19--Mantses-823=7104-- E.T-racy-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 <br /> INFO AMOUNT DUE ' AMOUNT REMITTED CASH RECEIVED SY DATE PERMIT"NO. <br /> l <br /> + EH13-24(REV.101631 <br /> EH 1426 <br />