Laserfiche WebLink
i <br /> - <br /> 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 /> Job Address <br /> City of Size PM <br /> Owner's Name Address SD hon <br /> c— <br /> Contracto Address r_:� License No � Phon �e <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �1 <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 /> NJ Specifications <br /> ❑ Gravel Pack EI Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern A5urface Seal Installed by <br /> Repair Work Done ❑ Type of Pump_.Q,,:A� H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {Na septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installat of nwilf-serue; Residence— Commercial_ Other <br /> Number of living units:_ -_Number of bedrooms �1 <br /> Character of soil to a depth of 3 feet:—�� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ~` <br /> ti- CapacityNo. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Founc StKm Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total leng e <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property ty Line- <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 must all or all req ed inspections. Complete drawing on reverse side. <br /> Signed X Title: Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Z:5 d Area G <br /> Pit or Grout Inspection by Date Final Inspection by ate �3 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 MOUNT DUE AMOUNT REMITTED CK 9 <br /> ASH RECEIVED BYDATE PERMIT'NO. <br /> + EH 13-24(FI EV.1/H 51 � <br /> EH 14-Za V_,�,CfL <br /> r <br />