Laserfiche WebLink
APPLICATION FOR <br /> R PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 51 <br /> 1601 E. HAZEL T ON AVE,, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N�EN��G <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 here 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 /> I Local Health District. <br /> Job Address Cit <br /> yLot Size PM <br /> Owner's Name �CGb Address <br /> I Phone d <br /> Contractor Address �} � T <br /> License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER- ` <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom O Manteca Dia. of WeII Excavation <br /> i <br /> Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing Specifications <br /> M Public y❑ Other p <br /> Cl delta Depth of Grout Seal <br /> Irri anon Type of Grout <br /> 9' -Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work Done Cl Type of Pump H p - <br /> State Work Done <br /> Well Destruction L2Well Diameter Sealing Material ;top 50'1 <br /> Depth <br /> Filler Material (Below 50') � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DE5TRUCTION i I (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet.- <br /> SEPTIC <br /> eet:SEPTIC TANKWater table depth <br /> Q Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal c } <br /> Distance to nearest: Well FoundationJ I <br /> Property.Line � <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED CIDistance to nearest: Well Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS I I Depth Size <br /> SUMPS — Number <br /> fel Distance to nearest: WeII Foundation <br /> DISPOSAL PONDS ❑. Property Line <br /> 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, and <br /> rules and regulations of the San Joaquin Local Health Dl <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 following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Gafifa." <br /> The applica call far all requi inspectio Cam fete drawing on re rse e. <br /> Signed X <br /> Title: .Dater <br /> FO EPARTMEN SE ONLY <br /> Application Accepted by — © r] <br /> Date ,Area �i <br /> Pit or Grout Inspection by Date Final Inspection by epi s <br /> Date <br /> Additional Comments: <br /> CI Stk- 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies ta: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO rry CASH RECEIVED 8Y DATE PERMIT'NO. <br /> +.EH13-24(REV.1/n 51 L✓.c ��_ f <br /> EH 14-26 `W ✓ fO"�A <br />