Laserfiche WebLink
,P APPLICATIONFOR'�P.ERMITpit <br /> SAN JOAQUIN LOCAL H5ALTH DISTRICT `` <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> f Te[ephohe (209) 466-6781 MAY I � [� <br /> 4 PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIRONMENTALHEALTN <br /> PERMITISEI�VF�S�. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descn a 1s application is <br /> made in compliance with San Joaquin County Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> z <br /> Job Address City Lot Size PM <br /> C , <br /> Owner's Name Address S*.. "���"-t� _ -- Phone ,! <br /> Contractor, G[ " Address 0, tiTc�c� License No. Q Phone T <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR_V OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES # t DISPOSAL FLD. - PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Kf Irrigation _Approx. DB th l I Eastern Surface Seal Installed by <br /> Repair Work Done er Type of Pump C. H.P. 6 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is 1 ! <br /> available within 200 fee <br /> Installation will serve: Residence— Commercial— Other i 1 <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table deji <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line " <br /> LEACHING LINE ❑ : Noy`&.L ngth of'lines a Total length/size r <br /> FILTER BED © Distance to nearest:_ Well *� Foundation Property Line s ' <br /> SEEPAGE PITS I 1 Depth Size : A �� { _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ^ 'w <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 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 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 California." + <br /> The applicant�11 for all require 'nsZ—Al <br /> ns. Complete drawing an a se side.Signed X__ - /f Title: t��7 _. Date: i Q <br /> FOk DEPARTMENT USE ONLY <br /> Application Accepted by Date ' Area <br /> Pit or Grout Inspection by Date Final Inspection by DateV��Z'�U F <br /> f ' <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 EI Manteca 823-7104 0 Tracy 8355-6385 <br /> Applicant - Return all copies to: Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:, CA 95201 <br /> v <br /> f, <br /> HE <br /> I CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> ;* 1', <br /> r.EH 13-24 IREV.5 H 51 <br /> EH 14-2e - q <br />