Laserfiche WebLink
491 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �] <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> o.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance N <br /> Local Health District. <br /> City��jj- Lot Size PM <br /> Job Address <br /> A)4 1T7', Phone 3 <br /> Owner's NameAddress <br /> Address Phone <br /> License No._��-.—� i <br /> Contractor L"' <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL LI ., OTHER 171PUMP INSTALLATION F1 SYSTEM REPAIR ElF <br /> DISTANCE TO NEAREST: SEPTIC TANK , _ -SEWER LINES <br /> DISPOSAL FLD- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy❑ Delta Depth of Grout Seal Type of Gtout <br /> Cl Other <br /> I`1 Public _ <br /> I I Irrigation _Approx. Depth l I Eastern 'Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump t <br /> H.P. State Work Done <br /> Weil Destruction ❑ Well Diameter a Sealing Material Stop 501 <br /> I Depth r Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I DESTRUCT50NV <br /> lNo septic syirt stem <br /> pefrrmiitted if public sewer is <br /> l Installation will serve: Residence— Commercial_ Other <br /> s <br /> Number of living units: Number of bedrooms * y <br /> r Character of soil to a depth of 3 feet: f 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 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> t <br /> SUMPS L1 lAtance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 .I <br /> d that the work will be done in accordance with San Joaquin county ordinances, state.laws, and <br /> I hereby certify that I have prepared this application an <br /> rules and regulations of the San Joaquin Local Health District. <br /> i rcify that in the performance of the work for which this permit is issued, !shall <br /> igna not <br /> Home owner or licensed agent's signature certifies the following: "I ce <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 applicant must call for all quired inspectio s. Complete drawing on reverse side. <br /> Signed Title: 4.1 Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> � 1�. Date,Z � " L Area IU <br /> Pit or Grout Inspection by ate Final Inspection by Date <br /> Additional Comments: G <br /> ❑-Stk 466-6781 ❑ Lodi 369-3 (3 Manteca 823 7104 -1 Tracy 835-6385 / <br /> /Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 •rc%�y(! <br /> FEE AMOUNT DUE AMOUNT REMITTEt7 CK RECEIVED BY DATE PERMIT NO. <br /> INFO z�+ y�/� } �{ <br /> + EH13-24tREV.tins) 1�•� �•� �� �'�� �� • .. <br /> EH 14-2e <br /> R <br /> n <br />