Laserfiche WebLink
' �"r'1 <br /> APPLICATION FOR PERMIT <br /> r SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE-STOCKTON, CA Fw <br /> Telephone (209).466-6781 <br /> PERMIT EXPIRES 1 YEAR 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 /> i.. 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 /> `tj� City Lot Size PM <br /> Job Address /1 <br /> Owner's Name Address — Phone �1 <br /> ` <br /> 3 7 3 Phone Contractor ddress �\ rucense No. <br /> � <br /> f <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT LJDESTRUCTION LJ <br /> PUMP-INSTALLATION, ,._--.SYSTEM_ ,REPAIR-Q OTHER "❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �°"1 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELC OTHER WELL PITS/SUMPS <br /> � s <br /> M AREA'CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLE <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Specifications ' <br /> f C35omestic/Private ❑ Gravel Pack El Tracy Type of Casing - <br /> 171 Public ❑ Other ❑.Delta x - Depth of Grout Seal Type of Grout <br /> �-yS <br /> El Irrigation _�pprox-Dep ❑❑ Eastern- Surface-Seal installed-by, <br /> Repair Work Done C]' Type of Pumpl Ea H.P. State Work Done <br /> y r <br /> 'Well Destruction ❑ Well Diameter Sealing Material )tap 501 � <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is { <br /> available within 200 feet.) <br /> tl ' <br /> Installation will serve: Residence f Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> CapacityNo, Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ F iMethod of Disposals <br /> Distance'to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> L <br /> FILTER BED ElDistance to nearest: Well Foundation Property Line <br /> f I. <br /> Number t" <br /> SEEPAGE PITS F1 Depth ; Size l-r <br /> I SUMPS L3 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El ! � - j - <br /> w rk will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> { hereby certify that I have prepared this application and that the wo <br /> rules and regulations of the San Joaquin Local Health District. 6�• <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 st I1 for all re fired inspections. Completes�dr//a--wing on reverse side. /� r <br /> Signed X <br /> ° FOR DEPARTMENT USE ONLY � � ' <br /> � Date �' Area <br /> G I <br /> Application Accepted by l <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: n , <br /> p Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k. CA 9520CK 01 <br /> F-rEE7 AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT"NO. <br /> INFO ° <br /> h + EH 1:3-24(REV.1/65l <br /> Eli 1428 <br />