Laserfiche WebLink
APPLICATION .FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. <br /> Jab Address } _� <br /> City 19'7(7/ev+ Lot Sized PM <br /> Owner's Name l Address Phone <br /> `Contractor = Address ff ,eZ_44S _License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST;_SEP_T.I,.0 TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> I ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k_. <br /> INTENDED USE ( TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> s t <br /> E ❑ Industrial y—O-Open''Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing <br /> Specifications <br /> '.❑ Public ❑ Other ❑ Delta Depth of Grout Seal "'"Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑,Eastern Surface Seal Installed by <br /> Repair-Work Done ❑ T _ * <br /> ype of pump Ii p State Work Done j <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50.1 <br /> t <br /> P Depth Filler Material (Below 501 '[! •n t 1, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION"O, REPAIR/ADDITION PC DESTRUCTION ❑ (No septic system;.permitted if public sewer is <br /> ' �` ,'' available within 200 feet.)` <br /> 1 <br /> Installation will serve: Residence commercial Other <br /> Number of living units: Number of bedrooms. `— ry <br /> i Character of soil to a depth of 9 feet: S/�7ti �► L e��m (i <br /> I T-- Water table'depth <br /> SEPTIC TANK ❑ T e/Mf"l, <br /> YP 9' Capacity No. Compartments <br /> } PKG. TREATMENT PLT..❑ 1 Method of Disposal <br /> r Distance to nearest: Well' Foundation Property Line <br /> ,LEACHING LINE No. & Length.of lines "' 4f 147�'. . ,Total length/size CA-cl <br /> `FILTER BED Cl Distance to nearest: <br /> Weli'l 392 r-- `'%3 FG <br /> _ Foundation Property Line <3D,A–T <br /> ,,SEEPAGE PITS ❑ Depth Size Number ti <br /> SUMPS ❑ 'Distance to nearest: Well "" foundation I F � <br /> Property.Line <br />'. .::• g DISPOSAL PONDS ❑ V, <br /> hereby certify that I have prepared this application andlthat 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. , ± ; s <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 /> I employ any person in such manner as to become subject to wa`rkman'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 ior which.this Pe- issued,I shall-employ;__ persons subject to workman's compensa <br /> tion laws of California." f t ,_ w' - <br /> : <br /> The applicant must call for 1 re fired inspections. Complete drawing on.-(ev5erse side. <br /> t Sfened �.. r. Title: 2Date:4L9 <br /> w FORP T USE ONLY <br /> Application Accepted by0!V Date Area' <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> i Additional Comments:�'�'' - <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑Manteca 823-7104 ❑ Tracy <br /> 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009, Stk., CA 95201 <br /> 4 - <br /> - z .FEE—-,, CK-4S , <br /> AMOUNT pUE `�AAAOUNT REMITTED RECEiVIb <br /> INFO CASH DATE PERMI7TN0. <br /> + EH 13241REV.1/65) <br /> EH 1428 <br />