Laserfiche WebLink
APPLICATION FOR PERMIT "1tt <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 0 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ���wvvv <br /> Telephone (209) 466-6781 �9a� <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 his 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 ations of the San Joaquin <br /> Local Health District. <br /> Job Address �!? vv<, /1s City Lot Size PM <br /> Owner's Name l r �! ' � Address _�M U '�` Phone <br /> Contractor Address 1276 License No.b �_Phone 77 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 4§i_ 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 /> 0 Industrial 4� Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ,*,Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (-1 Public 0 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> - <br /> I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by _ <br /> Repair Work Done 0 Type of Pump H.P. f State Work Done <br /> c <br /> Well Destruction ❑ Well Diameter _C?,d Sealing Material (top 501 <br /> Depth 1,09' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 RFRAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <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 /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L) 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 <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 su h manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following 'I a 'fy that i the pert ce of the work for which this permit is issued, i shall employ persons subject to workman's compensa- <br /> tion laws of Califor a." . <br /> The applicant mu 1 ar req it i ctidns. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> ^ FOR DEPARTMENT USE CKLY <br /> Application Accepted by 42Date Area ©��,, <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments.- <br /> 0 <br /> omments:❑ Stk 466-6781 ❑ Lodi 369-3621 0 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 <br /> INFO �AjM-OOUUNT DUE AMOUNT REMITTED CASH it RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24(REV.t/x51 <br /> EH 14-28 (/ <br />