Laserfiche WebLink
APPLICATION FOR PERMIT <br /> I4 <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 /> j ICornplete in Triplicate) <br /> I <br /> Application is hereby made to the San Joaquin Local Health District fora.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/pup and the Rules and Regulations of the San Joaquin <br />� <br /> Local Health District. <br /> Lot Size PM <br /> Job Address f <br /> Phone <br />` ,.Owner's Na Address . <br /> Contractor gv4z <br /> f Address � L e N [� Phor c� <br /> TYPE OF WELL/PUMP: T NEW WELL C3WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DIS PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ER WELL PITS/SUMPS <br /> j FOUNDATION AGRICULTURE WELL" <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS TION SPECIFICATIONS Dia. of Well Casing <br /> 11 Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation ; <br /> Type of Casing Specifications <br /> -L] Domestic)Private ❑ Gravel Pack' ❑ Trac yp g Type of Grout <br /> I'7 Public 17 Other - elta Depth of Grout Seal <br /> I I Irrigation _.Aper epth I I Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work pone ❑ of Pump - 1 <br /> s Well DestructionWeII Diameter Sealing Material Itop 50 <br /> ' '1 <br /> t✓ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l'I REPAIR/ADDITION I I DESTRUCTIO (No septic system <br /> m permitted if public sewer is <br /> availablristallation will serve: ,Residence__ Commercial Other <br /> Number of living units: Number of bedrooms " r <br /> Water table depth <br /> Character of soil to a depth at 3 feet: <br /> SEPTIC TANK it LlType/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG, TREATMENT PLT. Ell <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size- <br /> I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth _kSize _ Number <br /> SUMPS Ll Distance to'nearest: Well Foundation Property Line <br /> k <br /> DISPOSAL PONDS ❑ <br /> E 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 /> t certifies the following: "I certify that in the performance-of-the work for which this permit is issued;t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica ust call for all requi �inssp�ec�ttkaiins. Complete drawing on reverse side. ` <br /> k <br /> Title: Date: <br /> Sig <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by \ ( <br /> Oaten— <br /> Area —� <br /> Date <br /> Additional <br /> Final Inspection by Date <br /> =39- <br /> Pit or Grout Inspection by <br /> Additional Comments• <br /> ❑ Stk 466-6781 EIeca Lodi 369-3621 ❑ Mant823-7104 ❑ Tracy 835-6385ty� <br /> i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Silk., CA 95201 <br /> I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO / r <br /> + EH 13.24 IREV.r/R 51 -c:, <br /> EH 14-26 <br />