Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT gyp` <br /> rj 1601 E. HAZE i ON. AVE., STOCKTON, CA <br /> r �� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t� `, © �g� <br /> (Complete in Triplicate) ->k�ffi�a K� On is <br /> r` made to the San Joaquin Local Health District for a permit to construct and/or install the work her `c� t"�1�p�� �Mquin <br /> Application is heieby � <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an <br /> Local Health District, <br /> r f <br /> City �Q Lot Size PM <br /># Job Address., <br /> F <br /> Phone <br /> Owner's Name <br /> ax <br /> Address <br /> ansa No. X94 /3 Phone <br /> y <br /> Contra ctorl, ��' AddEess DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ISI WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> j PUMP INSTALLATION ❑ DISPOSAL FLD. /6D PROP. LINE <br /> r SEWER LINES <br /> DISTANCE TO NEAREST: SEPTIC TANK _ OTHER WELL PITSISUMPS <br /> 1 t FOUNDATION AGRICULTURE WELL <br /> 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Dia. of Well Casing (� <br /> ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation <br /> Cl Industrial AL1 Specifications ^I <br /> r � Gravel Pack X Tracy Type of Casing - <br /> DomesticlPrivate Type f Grout <br /> M Other 17 Delta Depth of Grout Seal <br /> FI Public - <br /> _Approx. Depth l 1 Eastern Surface Seal installed by , <br /> k 1 1 Irrigation — H.P. State Work Done — <br /> 6 � <br /> Repair Work Done ❑ Type of Pump <br /> k Sealing Material (top 501 k .� <br /> r Well Destruction ❑ Well Diameter Filler Material IBelow 50'1 <br /> j Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION l 1 DESTRUCTION I }.Jo septc availablelwi within permitted if public sewer is <br /> 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of`bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal ` <br /> PKG. TREATMENT PLT. ❑ Pra rt Line <br /> Distance to nearest: Well Foundation pe Y <br /> Total length/size <br /> LEACHING LINE CI No. & Length of dines Property Line � <br /> FILTER BED <br /> El Distance to nearest: Well Foundation p Y <br /> I. Size Number <br /> SEEPAGE PITS 1 Depth epth Property Line <br /> SUMPS L-1Distanceto nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,and <br /> rules and regulations of the San Joaquin Local Health District. he work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of t <br /> I employ any person in such manner as to become subject to workman's compensation laws cif 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 compansa- <br /> tion laws of California." <br /> The applicant ust call for all requir inspections.-Complete drawing on r verse side. / <br /> r Jc Title: Date: <br /> Signed X <br /> PDR EPARTMENT USE ONLY <br /> I ` Date � Area <br /> Application Accepted by _ <br /> Pit or Grout Inspection by lef, <br /> Date ' " Final Inspection <br /> r <br /> Additional Comments: 6 C r�%e�_ <br /> � <br /> i ❑ Stk 466-6781 ❑ Lodi 369-3621 ElManteca 823-7104 0 Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> K RECEIVED BY DATE jl�M�NO. <br /> AMOUNT DUE AMQUNT REMITTEDFEE HtNFOEH 1324(REV.1/M 51 � <br /> EH 14-28 <br />