Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heteby 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address W City J d fu lI�/ Lot Sire PM l <br /> Q 6 <br /> Owner's Name Address CleprePhone U <br /> Contractor AX1*2i14 Address.J. cense No, r� -3 Phone <br /> TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _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 /> ('1 Public f i Other ❑ Delta Depth of Grout Seal Type-of Grout <br /> I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by T <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') ` <br /> Depth Piller Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION ( ' (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms " r <br /> Character of soil to a depth of 3 feet: r Water table depth <br /> SEPTIC TANK 0 Type/M-iu Capacity No. Compartments' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal. <br /> ..m <br /> Distance nearest: Well Poundati- 4n. � Property.Line <br /> LEACHING LINE ❑ No. & Length'of lines f - - ,Total length/size i"1 <br /> � . <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r �r+ <br /> SEEPAGE PITS I I Depth Size _-Number ` } <br /> SUMPS 1_1 Distance to nearest: Well Foundation— `Property Line + <br /> DISPOSAL PONDS ❑ t, <br /> I hereby certify that I have prepared,this application and that the work will be done in accordance with San Joaquin county ordinances, statd laws, and <br /> rules and regulations of the San Joaquin Local Health Dotrict. <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 applicant must call for all re I s13-yo ns. Complete dra g on reverse side. <br /> S Titre: Date: "`rte <br /> AOR TMENT USE ONLY ,I <br /> Application Accepted by !/ Date Area <br /> a 1w ?iY . <br /> Pit or Grout Inspection by Date Final Inspection by Date-/ � j 1 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> l <br /> FEE <br /> INFO [,;;DUE AMOUNT REMITTED CASH CK 4 RECEIVED 8Y PATE PERIVtIT N4. <br /> +,EH 13-24(REV.1/n 5) Le <br /> EH 14-20 ! Q 1 J <br />