Laserfiche WebLink
P <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE T ON AVE., STOCKTON, CA <br />6 -5 - <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicates <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 �, - City Lot Size PM <br />Owner's Name f Address? r�C -moi Phone %off <br />Contractor Addr ss License No, Phone <br />YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ <br />DISTANCE TO NEAREST: SEPTIC TA X - <br />INTENDED USE <br />❑ Industrial <br />❑ Domestic/ Private <br />f'l Public <br />I I irrigation <br />Repair Work Done ❑ <br />Well Destruction. O <br />SYSTEM REPAIR OTHER ❑ <br />SEWER LINES DISPOSAL FLD. PROP. LINE <br />LTURE WELL OTHER WELL PITS/SUMPS <br />11YPE OF WELL PROBLEM AREA <br />❑ !Open Bottom ❑ Manteca <br />❑ Gravel Pack ❑ Tracy <br />71 Other Cl Delta <br />Approx. Depth I I Eas n <br />Type`o�ff Pump <br />Well Dia?t9eiet. <br />Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 <br />-ION SPECIFICATIONS <br />,04. of Well Vis: tion Dia. of Well Casing <br />Type of Casing Specifications <br />Depth of Grout Seal Type of Grout <br />Surface Seal Installed by <br />H. P, State Work Done <br />Sealing Material (top 50') <br />Filler Material (Below 501 <br />REPAIR/ADDITION 1 I DEST <br />Installation will serve. Residence _ Commercial <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK ❑ Type/Mfg <br />PKG. TREATMENT PLT. ❑ <br />Distance to nearest: Well <br />LEACHING LINE ❑ No. & Length of lines <br />FILTER BED ❑ Distance to nearest: <br />Well <br />Other <br />RUCTION�X(No septic system permitted if public sewer is <br />> available within 200 feet.) <br />Water table depth <br />Capacity No. Compartments <br />Method of Disposal <br />Foundation Property Line <br />Foundation <br />Total length/size <br />Property Line <br />SEEPAGE PITS I I Depth Size _ Number <br />SUMPS Ll Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS ❑ <br />IJ <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 D$trict. <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 ust call for all required ins ctions. Complete drawingon re rse side. <br />Signed X Title: .wh}✓l _ Date: <br />F. P EPARTMENT USE ONLY ct <br />Application Accepted by �� -„ 4 Date "i 1� LJ Area <br />Pit or Grout Inspection by /yam Datte___ / _ Final Inspection by Date /0 <br />= Y . -1- <br />Additional <br />l1 - <br />Additional Comments: I I "V 1 f L t <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Trac 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O <br />+. EH 13-24 Ott EV. i / H s ) <br />EH 14-28 <br />FEE <br />INFO WAMOUNT DUE <br />AMOUNT REMITTED <br />CA/SH� <br />8Y <br />DATE PERMIT'(N�CO../ <br />,1 <br />/RECEIVED <br />j <br />