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 1'YEAR FROM DATE ISSUED 1 <br /> t <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 /> Job Address <br /> Gity' Lot Size PM <br /> Owner's Name —� Address-. Phone <br /> Contractor ✓r�(/ +rs _Address ------ License <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑.. DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAY;-❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE U . <br /> FOUNDATION AGRICULTURE WELL rt yOTHEA WELL PITS/SUMPS O , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 9 4 <br /> ❑ Indusfrial? °❑ Open-Bottom—❑-Manteca-^-- �»-piavof Well-Excavation— �. Dia:o#-WeILGasing <br /> ❑ Domestic/Private.-- Ll Gravel Pack CJ Tracy Type of Casing .Specifications <br /> M Public <br /> f i Other f 1 Delta Depth of Grout Seal Type of Grout <br /> I 1 Irri ation <br /> 9 "1 �-Approx. Depth [ I Eastern .Surface Seal Installed by <br /> Repair Vti/ork!Done`. D Type of Pump H.P. State Work Done Y t <br /> Well Destruction, ❑ Well Diameter Sealing Matefiai {top 501 <br /> 1 Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION f I (No septic system permitted if public sewer is <br /> available within within 200 feet.) <br /> Installation will serve: Rest encs X Comrrlercial�--'Other o <br /> Number of living units: Number of bedrooms r +� <br /> Character of soil to a depth of 3 feet: <br /> }.- Water table depth. � <br /> SEPTIC TANK 1 T. ❑ Type/Mfg �� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ $ r,• Method of Disposal <br /> t. Distance to nearest: Well; .=" Foundation Property.Line <br /> LEACHING LINE No. & Length of linesTotal length/size <br /> } ++ <br /> FILTER-BEp ❑ Distance to nearest: Well Foundation -% Property Line 1 <br /> SEEPAGE PI'S'7.11 I 1 Depth <br /> Number <br /> SUMPS T Ll Distance to nearest' Well f Foundation Property Line <br /> + <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 San Joaquin Local Health Di§frict t <br /> Home owner„or license ag nt's signature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not r <br /> employ any person.in ch anner as to become subject to workman's compensation laws of California.”Contractor's hiring or sub-contracting signature <br /> certifies the following "'1 rtify that in the performance of rk for which this permit is issued, i shall employ persons subject to workman's compensa- <br /> tion laws of Califon »., w - <br /> The applic t ust I fo�,al uir �'o' ,.C' a drawing on re arse side. <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> f, --- Date � Area_L�_ - <br /> Pit or Grout Inspection byDate Final Inspection by Date �'��- <br /> r <br /> Additional Comments: z, <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 r <br /> FEE <br /> !s! <br /> INFO QAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. <br /> +.Eli113.24(FiEv.;/K5) <br /> EH 14-26 <br /> v V <br />