Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> -Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED ' <br /> `(Complete n Triplicate). *vx, f <br /> v . <br /> Application is hereby made to the San Joaquin Local Health District fora 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 Lot Size f K 75 �Ir PM <br /> ft. <br /> Owner's Name ' •Address S � i <br /> Phone <br /> i <br /> Contractor _.Address _ -iLicense lVa. <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELD 171 -��-�- WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ' — <br /> SYSTEM"REPAIR ❑.c✓" OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL •PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Weil Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T <br /> „n ❑ Public YID of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done 1 <br /> Well Destruction LJ -Well Diameter Sealing Material (top 50') ' t 1 <br /> Depth Filler Material (Below 50') € <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR7ADDITION'❑ "DESTRUCTION (N3 septic'system permi7ftedifublic sewer is <br /> able within 200 feet <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg -Y< "t CapacityNo. Compartments <br /> f PKG. TREATMENT PLT. Ll '"' _. <br /> Method of Disposal <br /> Distance to riearest: i y Well__ Foundation Property Line 1 <br /> LEACHING LINE ❑ No. & Lengthof lines ,. , <br /> Total length/size <br /> - " FILTER BED ❑ Distance to nearest: Well # Foundation Property Line <br /> SEEPAGE PITS '❑'Depth Size Number <br /> SUMPS'- ❑ Distance to nearest: .f Well Foundation Property Line <br /> DISPOSAL PONDS ❑ f <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance <br /> rules aril! regulations of the San Joaquin Local Health District. s, state laws, and <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 Paws of California.-Contractor's hiring or sub-contracting signature r � <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 y cornpensa- <br /> tib_n laws of California." <br /> THe applicant ust call for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: Date <br /> FOR DEPARTMENT USE UNLY­'"""""""'" — <br /> Application Accepted by Date <br /> . 3� TY Area <br /> IPit or;Grout Inspection by Date Final Inspe by Data <br /> Additional Comments; �� G `2 1, ?) <br /> C , ° ' `� � <br /> C7 Stk 466-6781 ❑.Lodi 369-3621 Manteca 823-7104 ❑ Tracy 12 1r5t <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., A 95201 <br /> FEE CK rr ItiLC <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT''NO. <br /> CASH prat �q� <br /> + EH 13-24(REV,4/85) <br /> EH 1428 <br />