Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> i 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED <br /> f (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 /> f 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 /> y Local Health District. <br /> Job Address tdS�� City fTrl. Lot Size PM <br /> I Owner's Name /vj¢vv Address Phone <br /> Contractor � `� Address �— ---�L-icense-No. Phone <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 WELLS OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA{ CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca V Dia. of Well Excavation Dia. of"Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i"1 Public ❑ Other * ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I irrigation _..Approx. Depth t I,E�Eastern "" " Surface Seal Installed by / _ <br /> Repair Work Done ❑ Type of Pump H.P., State Work Done ON <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 pn <br /> Depth Filler Material (Below 501 \' <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION VrDESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.i' <br /> �., <br /> Installation will serve: Residence �Commercial_ Other <br /> Number of living units: _ Number of bedrooms _._ <br /> Character of soil to a depth of 3 feet: ' "^a Water table depth <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 No. & Length of,lines /-1` Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 7�-:- 4undation p Property Line .'0 <br /> SEEPAGE PITS Depth Z S— Size 33 — Number t, <br /> SUMPS � --fel--Distance to-nearest:• - Weil, t' Foundation 5-01tPropertyLine fy7` <br /> I 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 <br /> rules and regulations of the San Joaquin Local Health.DPstrict. <br /> r 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 call for all required inspections. Complete drawing on reverse side. <br /> f Signed X lll�-.2/Z. Title: �s���� Date: Z ��R p p <br /> MR DEPARTMENT USE ONLY <br /> Application Accepted by �.. Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Y Date <br /> Additional Comments: - <br /> ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> IFEE O MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE e PERMIT'NO. <br /> i <br /> r.EH13-21(REV.1iN5) 35C <br /> EH U-28 LJ V l (/ <br />