Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �e�_ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <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 /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wellipump and the Rules and Regulations of the San Joaquin <br /> Local Health District. V <br /> varl <br /> Job Address /09 �� City Lot Size Iii PM <br /> T�Owner's Name Address Phone <br /> Contractor kp Address -54? ae License No. Phone <br /> i T WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION.' RICULTURE WELL - OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM ARTA--t94i4j.TFILICTION SPECIFICATIONS <br /> ' ❑ Industrial ❑ Open Bottom' ❑ Manteca Dia. of We ation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I <br /> y r'1 Public ❑ Other ❑ Delta Depth.of Grout Seal Type of Grout <br /> I I Irrigation ..Approx. Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P: State Work Done_ <br /> i Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> I Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> t Installation will serve: )Rasidence— Commercial— Other . <br /> Number of living units: .` Number of bedrooms t <br /> Character of soil to a depth ofII3.feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments <br /> PKG. TREATMENT PLT. ❑ a Method-of­Disposal <br /> l <br /> Distarice to nearest: 'Well Foundation Property Line r <br /> I <br /> LEACHING LINE ❑ No f& Length of lines Total length/size <br /> t <br /> f FILTER BED ❑ Distance to nearest: Well Foundation f Property Line t <br /> SEEPAGE PITS 11 Depth Size Number ' <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line f <br /> DISPOSAL_ PONDS ❑ �' <br /> 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 regulations of the San Joaquin Local Health Diltrict. <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 /> 4 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall eploy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantt c I f r all required in clions. Complete drawing on reverse side. <br /> Signed X Title: 841/1 Date: <br /> ~� <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Date 00 Area <br /> Pit or Grout Inspection byDa Final Inspection by Date <br /> Add itional-Cortiriienfs: t {� <br /> I{ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ IM teca 823-7104 O Tracy 835-63$5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201t�A <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 4 SR RECEIVED BY DATE PERMIT NO. <br /> INFO �} <br /> +.EH13"T4 IREV.t i a 51 b <br /> EH 14-26 �•/ <br />