Laserfiche WebLink
f <br /> APPLICATION FOR PERMIT 4/6 7 / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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. <br /> �-:.�L-LkJ7 C-o-ta 1 <br /> �� �t..ti-C �-Cu 7/City q77, <br /> Job Address r - tat Size PM <br /> U ? <br /> Owner's Name (.+� �' r "y�'9' Address got Phaneq3 /"I Y 0 i <br /> Contractor !u ' 1`i Address 4 f`L 4 Ca-k License No/(`�3 Phone 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION U-` SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack }❑ Tracy Type of Casing Specifications <br /> ['I Public D Oiher F1 Delta Depth of Grout Seal Type of Grout <br /> i­I'hrigation .3. --.,Approx. Dep h I 1 Eastern Surface Seal Installed by <br /> Repair Work Done F' Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 <br /> Depth Filler.Material IBelow 501 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION f I (No septic system permitted if public sewer is <br /> -» --� available within 200 feetA <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms It <br /> Character of soil to a depth of 3 feet: Water table depth �} <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines T _ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Dilarict. <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." <br /> The applicamus call for a required inspections. Complete drawing on reverse side. <br /> Signed X Vd �� } <br /> Title: /� �?ilDate. <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by C, Date Area <br /> Pit or Grout Inspection by Date. Final Inspection bQ �^'� '' Dat.*:: O—7U <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 /> .F.4 <br /> FEE DONT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NQ <br /> INFO / CASH r/, I �j 190-19wro <br /> [ <br /> +.EH13-241REV.I/nsl 35 fl1{.J C1.� W'!� i� <br /> EH 14-2e .J �L <br />