Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (2091466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> madeApplication is heieby Bance <br /> 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 /> City <br /> Lot Size PM <br /> " <br /> Job Address G <br /> Phone CS ' <br /> Address <br /> Owner's Name <br /> + 1 License No. Phone <br /> Contractor <br /> L Address DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: NE WELL ❑ WELL REPLACEMENT 13 <br /> SYSTEM REPAIR OTHER ID <br /> Y PUMP INSTALLATION ❑ DISPOSAL FLD. POOP. LINE <br /> SEWER LINES <br /> IDISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION _�— -_- ---- <br /> TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I INTENDED USE Dia. of Well Casing <br /> � Dia. of Well Excavation <br /> 5❑ Industrial ❑ Open Bottom ❑ Manteca , "`k Specifications <br /> ❑ Tracy !Type of Casing <br /> Domestic/Private ❑ Gravel Pack Type of Grout — <br /> ❑ Other 171 Delta Depth of Grout Seal <br /> IY 1 <br /> Public ' S <br /> Fla Seal Installed by <br /> I I Irrigation _�Approx. Depth I 1 Eastern State Work Done �— <br /> e _' <br /> Repair Work Done ❑ TYP ofPum-p: — /j Sealing Material (top 50'} <br /> — <br /> .Well Destruction ❑ Well Diameter f Filler Material (Below 50'1 <br /> _ 3 Depth <br /> TYPE.OF: SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I I DLSTRUCTION I I alvailablelwthin 700 feet.) if public sewer is <br /> ( SZ <br /> ' Oth <br /> Installation mss. <br /> ion will serve: Residence Commercial <br /> Number,of living runits: Number of bedrooms Water table depth rr j�► <br /> ' Character of soil to a depth of 3 feet: Capacity ` No. Compartments <br /> k SEPTIC TANK ❑ Type/Mfg - -� <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Foundation Property Line Yy� <br /> Distance to nearest: Well " <br /> 1 Total length/size <br /> ° ',.. <br /> LEACHING LINECl Na. & Length of l es Property Line <br /> ❑ Distance to nearest: Well Foundation P Y �lC <br /> FILTER BED 1 J <br /> I I Depth { Size Number <br /> SEEPAGE PITS Foundation Property L�e----- � <br /> SUMPS # ❑ Distanceo nearest: Well <br /> !` 'DISPOSAL PONDS ❑ ~ � <br /> 1I 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,regulatioris of the San Joaquin Local Health District. �/ <br /> jHome 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 shalt/nat <br /> employ any person in such manner as to become subieci to workman's,compensation laws of..California." Contractor's hiring or sub contracting signature <br /> certifies the fol! 'n I certify that in the performance of the.wo`rkfor which this permits issued, I shall employ subject to workman's compensa <br /> g: „ �' <br /> }tion laws of C lif . <br /> ,The appli nt stjcall for all r q fired in ctions. Complete drawing on reverse side. <br /> f Date: <br /> Title: <br /> I Signed X _ <br /> ( 4 OR DEPARTMENT S£ ONLY <br /> Date <br /> Area <br /> Application Accepted by <br /> Final-Inspection`by Date <br /> Pit or Grout Inspection by <br /> Date— <br /> Additional Comments: 835-6385 <br /> ❑ Stk 4fi6 fi781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy <br /> )+ Applicant Return all copies to: Environmental Health <br /> Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.., CA 95201"" —"� <br /> FEE AMOUNT REMITTED <br /> CK RECEIVED By DATE PERMIT'NO. <br /> AMOUNT DUE CASH <br /> r INFO <br /> ..EH 13-24 IREV.t/K5) <br /> EH 1,4-2e y <br />