Laserfiche WebLink
W <br /> APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT p� <br /> 1601 E. HAZETON AVE., STOCKTON, CA f _ <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 11,YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby[Wade 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 /> C <br /> PM <br /> City Lot Size <br /> Job Address <br /> Ow 's Name t{de� Address Phone <br /> I er �� - <br /> tltl <br /> Contractor Address License No. � Phone <br /> TYPE OF WELL/PUMP: NEW WELL�❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:`SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrials EJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0_ Domestic/Pr`ivate=`" ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> fl Public Cl Other Q Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation -Approx. Depth I 1 Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. Stare Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION i, REPAIR/ADDITION l l DESTRUCTION (No septic system permitted if public seweJ�sl_ll <br /> available within 200 feetI Installation will serve: Residence —""'Commercial____ Other �Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: �`" ''"a � ""=Water-table depth <br /> SEPTIC TANK ❑ Type/MfgCapacity No. Compartments <br /> ` PKG. TREATMENT PLT. ❑ 1 Method of Qispasal <br /> Distance to nearest: Well Foundation Property Line <br /> i ! <br /> R <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wellj Foundation a Property Line <br /> SEEPAGE PITS I I Depth —SizeF Number <br /> SUMPS L� Distance_to nearest:--+'"Wel(' Foundation -4-Property line }ri <br /> DISPOSAL PONDS w ❑ <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andl� <br /> rules and regulations of the San Joaquin Local Health District. I11 <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 follow' : 111 a 1 rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compens — <br /> tion laws of Calif r <br /> The applicant s r all required-inspections:-Complete drawing on-reverse side." � <br /> t-+ r Date: . , <br /> YSigned X Title: l <br /> F R DEPARTMENT USE ONLY <br /> Date 3 Area <br /> Application Accepted by <br /> f Date Final Inspectio_nb / Data <br /> Pit or Grout Inspection by <br /> t <br /> Additional Comments: IO � <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 /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-241REV.1/851 �+ ����• <br /> EH 14-2e <br />