Laserfiche WebLink
""* = APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Iq <br /> Job Address 09055 Q City Lot Size PM <br /> Owner's Narr /�/lC.�t. /f Addrss Q 12 r_ —�er.� Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0­ <br /> PUMP <br /> _ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER_ ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 'PROP. LINE (JQ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL V SPITS/SU r� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial El Open Bottom 11 Manteca Dia. of Well Ea6vati D Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty mg Specificitions <br /> i'l Public ❑ Other CI Delta Depth of Grout Seal Type of.Grout <br /> I I Irrigation --_Appro)( Eastern a Surface Seal Installed by _ <br /> Repair Work Done of Pump H.P. State Work Done, d <br /> Well D ion ❑ Well Diameter Sealing Material Itop 501 I <br /> Depth ` Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1.1 DESTRUCTIO ]'(No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity r -' No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal M <br /> Distance to nearest: Well Foundation�`� Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation - Property Line <br /> a <br /> 4 <br /> SEEPAGE PITS i'I Depth Size Number <br /> 1 <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL. PONDS ❑ <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 iE <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 /> w <br /> The licant m call for all required inspections. Complete drawing on reverse side. /d Q <br /> Signed X Title: — Date: ,�„ �/d �d L <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. <br /> a EH 13-24(REV.I/K sl - 00 <br /> EH 14-26 <br />