Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. �HAZEILJON�AVE., STOCKTON, CA <br /> Telephone(209) 466-6781 I <br /> i 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 /> f : <br /> i. <br /> Job Address CitQr Lot Size PM <br /> t / r <br /> Owner's Name Address Phone <br /> 3 - <br /> 4 <br /> Contractor G Address 7i License No.1Z J?73 Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES. DISPOSAL FLD. PROP. LINE <br /> FOUNDATION;— AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> a <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑��In�dustrial is 1 -1 - ❑Open Bottom ah7 Manteca' "","Did-of Well Excavation Dia- of Well Casing <br /> F L�DomesticlPnvate LiJGravel Pack ❑ Tracy; Type Casing } AVC Specifications d Abd <br /> 1-1 Public ❑ Other elta' Depth°of Grout Seal ype o Grout i <br /> I I Irrigation --Approx. Depth ! I.Eastern ;-Surface` ealll'tlrlstalled by. <br /> Repair Work Done LFr' Type of Pump 3+S It2�Ii'.P`" it •` `� �K1) State Work Done_ ax- <br /> Well Destruction ❑ Well Diameter l� ! Sealing Materialt(top 50') f <br /> Depth Fillet-Material (Below"50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLLATION'I I REPAIR/ADDITION 11' DESTRUCTION I I iNo septic system permitted if public sewer is <br /> i a f available within 200 feet.)el <br /> \� <br /> Installation will serve: Residence_ +Commercial Other . CvJ <br /> _ _ _ W <br /> Number of living units: Number",of bedrooms r <br /> Character of soil to a depth of 3 feet: � • � Water tabl�:deptFi�,f �.- <br /> _ _ <br /> SEPTIC TANK ❑ Type/Mfg_ Capacity No. Comps"rtments <br /> �PKG. TREATMENT PLT. ❑"E " t Method of Disposal <br /> ,. <br /> + Distance to nearest: Well Foundation rProperty Line "'t' ►t <br /> LEACHING LINE ❑ No. & Length of lines t Total0ength/size <br /> FILTER BED ❑ Distance'to nearest: Well Foundation Property Line � + <br /> SEEPAGE PITS I'I Depth ..-Size Number <br /> a ° <br /> SUMPS Ll 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 Di?;trict. 1 <br /> Home owner o nt'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 rson in such m net as to become subject t workman's compensation laws of California."Contractor's hiring of sub-contracting signature <br /> certifies t following: "I certif that in the m nc a work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taw of California." <br /> The ap licant or requir i omplet drawing on <br /> Signed Title: OF, ate: <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by A. y res kw, . ,wr-.�, Date Area l <br /> Pit or Grout Inspection by Q �J Ww Final Inspection by Date I <br /> Additional Comments: <br /> ❑ Stk 466-6781 . ❑ 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 /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'No. <br /> INFO ///C''}}}ASH f J IN-13/ <br /> +.EHEH 14-28 1REV.1/H51 D <br />