Laserfiche WebLink
APPLICATION FOR PERMIT : w , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL.T ON AVE., STOCKTON, CA ! <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRESI YEAR FROM DATE ISSUED,4 <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 /> s ry -� <br /> ' j <br /> Job Address City Lot Size PM f <br /> A. <br /> Owner's Name Address �,� 4 Plane r91 <br /> ? <br /> �' S. - , <br /> SSE Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ vw `a, WELL REPLACEMENT D. �� 'DESTRUCTION LJ-- -�--�—• PUMP INSTALLATION ❑ R �.-='SYSTEM REPAIR,LJ " "OTHER ❑ '"'" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW.ER_LINES - -d DISPOSAL-FLD. PROP. LINE <br /> t FOUNQATION. AGRICULTURE WELL�n tg BOTHER WELL" PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well"Casing _ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public k ❑ Other ❑ Dekta "~""Depih of Grout Seal a Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seat Installed <br /> Repair,Work Done ❑ Type of Pump I H.P. i '-"�State or one <br /> Well Destruction ❑ Well Diameter § Sealing,Material (top 501 <br /> Depth v Filler Material (Below 501 f <br /> JW <br /> TYPE,,OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION,_ {No septic system permitted'if public sewer is <br /> vailable within•ZOO-feet.l ..'� <br /> Installation will serve: Residence <br /> Commercial Other. 1 <br /> Number oflliving units: Number'of bedrooms _ <br /> f 1 . <br /> Character of soil to a depth of 3 feet: v Water table depth <br /> SEPTIC TANK D T r <br /> ype/Mfg ! Capacity Na. Compartments* <br /> PKG. TREATMENT PLT. ❑ Method of Disposal / <br /> '-�• .k '» <br /> i Distance to nearest: Well, Foundation Property Line, <br /> s <br /> mak; L <br /> LEACHING LINE D No. & LengtF of lines Total length/size" <br /> FILTER BED 1 12Distance to nearest: Well Foundation � Property Line" ` v <br /> SEEPAGE PITS ❑ Depth ° Size w Number +� a <br /> i•. . <br /> SUMPS f ❑ Distance to nearest: Well Foundation 3 Property Line <br /> DISPOSAL PONDS ❑ <br /> """`"'-I hereby certify that 1 have prepared this application and that the work will be done in accordance with Sant oaquin county ordinances, state laws, and 1 <br /> s'-4v rules and regulations of the San Joaquin Local Health District. . <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performs ce.of thework 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 Celifornia." 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 /> Thie pplic t ust call for a uir inspections.t Complete-d�rawing on_r " aide. <br /> " <br /> AC <br /> k Signed Title: Date:, <br /> a # FOR DEPARTMENT USE ONLY <br /> ACF <br /> pp(cation Accepted by Date �r Area <br /> Pit or Grout Inspection <br /> cb�yQ Date Finaall�I)nspection by + - Date L <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3&rk2ll ❑ Manteca 823-7104 ❑ Tray — k� <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. H elton Ave., P.O. box 2004, Stk., CA 9520 <br /> FAMOUNT DUE AMOUNT REMITTED <br /> INFO /.CA�SHTRECEIVED BY DA�TE PERMIT'NO. <br /> + EH 13-2 /REV. Z. <br /> EH 14-26 <br />