Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> HAZELTON ON AVE., STOCKTON, CA r <br /> 1601 E. HA � <br /> Telephone (209) 46,6-6781 rr,' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDTJVV/&0� '� <br /> (Complete in Triplicate) FFRA R• IAL <br />• �' � H��+� plication is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her n the-San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulati <br /> Local Health District. 6 <br /> �, � Lot Size PM <br /> Job Address <br /> 77 � City <br /> b AddressQ Phone <br /> Owner's Name p <br /> ��f-f f Addtes d License No.Z7 Phone <br /> C Dirt rotas <br /> TYPE OF WELL/PUMP: _NEW WELL ❑ WELL REPLACEMENT F-1DESTRUCTION ❑ <br /> P NSTALLAT10N �Jyr SYSTEM REPAIR ❑ OTHER © e <br /> ❑ISPOSAL"FLD�`" 'PROP:.LINE <br /> DISTANCE-TO-NEAREST; `SEPTIC-TANK`: SEWER-LINES" - S <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;`F5 <br /> ef �+ <br /> ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excav tion <br /> f" ,�Dia".-of Well Casing <br /> Type of Casin Specifications <br /> Li Domestic lPrivate Gravel Pack `Tracy YP g T e of Grout <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal / YP_� <br /> « ��t:4 - <br /> lrrigation .-Approx. Depth I I East/ern Surface Seal installed by �� !!�ff7. <br /> p r-� � H p State Work Done:_ <br /> Repair Work Done ❑"-- Type of Puin � <br /> Well Destruction ❑ Weil Diameter Sealing Material Itop 501 } . <br /> Depth W Fillet Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1.1 DESTRUCTION l I (No septic'system permitted if public sewer is <br /> available.within 200 feet.) <br /> Installation will serve: Residence— Commercial <br /> Other <br /> Number of living units: Number of bedrooms <br /> {' <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> k SEPTIC TANK LJ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> j PKC. TREATMENT PLT. ❑ � <br /> ` Distance to nearest: Well Foundation Property ine <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER SED ❑ Distance to nearest: Well Foundation Property Line <br /> _ SEEPAGE PITS 11 Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> will be done-in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work <br /> rules and regulations of the San Joaquin Local 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." Contractor's hiring or sub-contracting signature <br /> certifies the fallowing ) rtify t tin the performance of the work for w_h_i_ch_this permit is issued,-1 shallemploy persons subject to workman's compensa- <br /> tion laws of California." � <br /> l The applicant,rnu� all f req_ �inspaGtr n,/. Complete drawing on reverse side. <br /> Signed <br /> y Title: 1 - Date: <br /> 3 FOR DEPARTMENT USE ONLY <br /> . •. s Date Area <br /> Application Accepted by <br /> � � i <br /> I Final Inspection by Dated <br /> r Pit or Grout Inspection by Date s <br /> • s{ <br /> Additional Comments: <br /> �_• { ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.,Box 2009, Stk., CA 95201 <br /> 9 <br /> FEE AMOUNT DUE - 4MOUN7 REMITTED CASK{ RECEIVED BY DATE, <br /> PERMIT NO. <br /> INFO WOW <br /> � EH 13-21(REV.I/ri 5) <br /> EH 14-28 <br />