Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—ION AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)., . ,<r.1C.— <br /> Application <br /> C.—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 Joaduin County Ordinance No.549 for sewage or No. 1662 for well/pump-and the Rules and Regulations of the San Joaquin <br /> Local Health District. /, - ,y <br /> i <br /> Job Address IYA — City �� Lot Size Y PM <br /> Owner's Name r G "� Address v W Phone(53 5~ <br /> Conlra'cto's Name>. t cd Z � License No. ?G .. ___ _.�Qhone _ <br /> TYPE OF WELL/PUMP:° I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION;❑ <br /> PUMP INSTALLATION F1SYSTEM REPAIR ❑ OTHER ❑ <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. ! PROP. LINE <br /> ',,,,FOUNDATIONr r1 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WEU! PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bolitom ! ❑'Manteca Dia. of Welf-.Excavation Dia. of Well CasingON <br /> + , <br /> El Domestic/Private ❑ Gravel Pack k ❑ Tracy Type of Casing ' s Specifications �) <br /> f ❑ Public ❑Other ❑ Delta Depth of 6r66t'Seal. r: Type of Grout <br />} � ' t <br /> L1 Irrigation —LApprox. Depth 0 Eastern Surface Se&Instilled by—Repair Work Done ❑ Type of Pump I H.P. �"` State Work Done 1 ~ <br /> Well Destruction ❑ Well Diameter t Sealing Material (top 501 4, T <br /> Depth Filler Material (Below 50') i U} <br /> F TYPE OF SEPTIC WORK:, NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> g available within 200 feet:) <br /> Installation will serve: .Residence Commercial_ Other <br /> Number of living units:) Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg '< -cis Capacity e22 �� No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to,nearest: Well /00 / Foundation_ /t2 Property Line fe _ <br /> LEACHING LINE ElNo. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundations Property Line = 1 <br /> SEEPAGE PITS 171, Depth ^Size- <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•acdancee witliSan Joaquin county ordinances, state laws, and <br /> rules and regulations of the)San Joaquin Lo6al'Health District. <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." Contractors hiring or sub-contracting sigr ature <br /> certifies the following: "I certify t in the performance of the work for which this permit is issued,I shall employ parsons subject to workman's compensa <br /> tion laws of Cali or <br /> The applicant at c I r all quirk' e drawing on reverse side. <br /> t Date:Title: Com'N� �' <br /> Signed s:' <br /> FOR DEPARTMENT USE ONLY 1 �� l <br /> i <br /> Application Accepted by Date i Area <br /> r t <br /> Pit or Grout Inspection by Date - Final inspection by Date <br /> Additional Comments: j <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE i <br /> INFO AMOUNT DUE <br /> AMOUNT REMITTED C- SH 6 '►REEECEIVED BY DATE'i"�' " PERMIT"N0. <br /> + EH 13-24 4REV.10/831 <br /> EH 10.26 .. _ <br />