Laserfiche WebLink
1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE_ ISSUED <br /> IComplete 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. TMs 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 /> - <br /> Job Address !�,_... Q _� rfl�/c- t/ X City Lot Size A PM <br /> Owner's Name / f..- / 4-0_— C _. dd(ess SfD f Imo•__--- Phone <br /> Contractor (�' �1-- �., ryosu Address _ fd !` Ztic,l License No,____Phone = <br /> TYPE OF WELL,'PUMP­,_ NEW WELL ❑ WELL REPLAPrEMENT L7 DESTRUCTION F <br /> PUMPjINSTALLATI.ON ❑ SYSTEM REPAIR U ,-•� OTHER ❑ <br /> E TC NEAREST: SEPTIC TANK SEWER LINES _.._._.�__�_ DISPOSAL FLD..___-P-R-U,P--UN <br /> _ OUNDATION ___. _._ AGRICULTURE WELL _.......___._._..._ OTHER WELLPITS/SUMPS <br /> �._......_. r <br /> INTENDED USE TYPE OF WEL M AREA CONSTRUCTION i EC�ATIONS 1 <br /> • Industrial ❑ Opep Bottom 17 Manteca 'aYe I Excavation_...._._ Dia. of Well Casing <br /> ❑ DomestirrPrivate L: Greuel Pack ❑ y'_�Type of Casing.___. Specifications <br /> C] Public fl Other Cl Delta Depth of Grout Seal Type of <br /> I I Itriyation -. p_ox. Depth t I Eastern Surface Seal Installed by___.__............ <br /> Repair Work f__, Type of Pump H.P. �. _ State Work Done <br /> Wei estruction Cu Well Diameter Sealing Material (top 50') <br /> Depth Filler Material 16elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION DESTRUCTION I i (No septic system perrnitted if public sewer is d <br /> f �; �{`� � available within 200 feet-) <br /> _�� <br /> Installation will serve: Residence Commercial ° f Other <br /> i-`X�l v 4 <br /> �- { <br /> Number of living units: �.__._ ;Number of bedrooms-r_�"�._..__._ 1 p <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK � T /Mfg Capacity /aO No. Compartments t <br /> PKG. TREATMENT PLT _ _ Method of Disposal <br /> Distance to nearest: WAIL`�o1Foundation _ Property Line <br /> LEACHING LINE �\ No.,& Length of lines Total length/size 9.d 7 <br /> FILTER BED J Distance to nearest: i Well 2�Y�_ -'FounaHon Property Line <br /> SEEPAGE PITS 1 Depth I Size Number .� <br /> SUMPS L� Distance to nearest: Well Foundation_� Property-Line <br /> DISPOSAL PONDS i:_; ( � <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin Local Health D3trict. ,,. <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 /> 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.'.' I- —..w - <br /> The applicant must call f-q-r all required inspections. Complete drawing on reverse side. / <br /> Signed X Title: Date: <br /> r t� FOR DEPARTMENT USE ONLY <br /> Application Accepted by ����-+�.. Date '' Area <br /> Pit or Grout Inspection by Date Final inspection by ---Date !! <br /> Additional Comments: <br /> C Stk 466-6781 U Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> INFO <br /> EEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. <br /> r.EH 3-24( V. bl ��VEH 1 - v /` � / ' <br /> r <br />