Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �` "' L City Lot Size PM J. <br /> Owner's Name) + ( IV Address__ Phone <br /> Contractor L—G-6'V RL-Tk-�JAL,LAddress :3Jo c- - PLLicense N6. Phone �J 55c� <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel'Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public C2 Other ; ❑ Delta�' Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ° t--4pprgx. Depth F] Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.R. State Work Done <br /> Well Destruction ❑ Well Diameter r Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is <br /> available within 200 feet.i <br /> Installation will serve: Res(dence ` Commercial_ Other <br /> Number of living units: - Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: _Nth i) ,�� r�U _-_ S 'r`W� f table Hepth �� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well FoundationProperty Line <br /> --�t)b�� W FN-fi�11U <br /> J� <br /> LEACHING LINE. El No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> i <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. <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 subcontracting signature, i <br /> ce es the following:"I ce ify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- , <br /> tiori la California." <br /> The applica t m t call for all qui d iinap Icions.AomFdrawing on reverse side M1 <br /> Signed Title: [�� + �'� '� _,- Date: <br /> r— <br /> ___ FOR DEPARTMENT USE ONLY <br /> Lip—Accepted by Date LArea <br /> I <br /> Pit or Grout Inspection by Date Final Inspection y T Date <br /> I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El.Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> + EH 13-24(REV,t/e s} !_ 4+ ' S c�/� 5`� <br /> EH 1426 � � <br />