Laserfiche WebLink
�. APPLICATION FOR PERMIT } <br /> S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` 1601 E. HAZE T ON AVE., STOCKTON, CA ` <br /> Telephone (209) 466-6781 <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 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 /> �3 `� -� Cit � 4 dfLot Size PM <br /> Job Address Y (� j6 <br /> i y� <br /> I Owner's Name,I'7 LIA !t!i s CC Address Phone <br /> Contractor ss-40� License NoA4 4W Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ <br /> PUMP INSTALLATION'171 SYSTEM REPAIR ❑ OTHER ❑ <br /> h <br /> } D71NTE2NDED <br /> rUSE <br /> C SEWER.LINES DISPOSAL FLD. PROP. LI <br /> r FOUNDATION RICULTURE WELL OTHER WELL PITS/SUMPS <br /> TYPE OFWELL PROBLEM AREA C TICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excav Dia. of Well Casing <br /> 1: ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> F'7 Public ❑ Other Delta Depth of Grout Seal y Grout- <br /> I ] <br /> rout <br /> I ] Irrigation Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ype of Pump H.P. State Work Done <br /> Well De ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC.WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION o 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 /> F€ Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT. ❑ s Method of Disposal (f�� <br /> Distance to nearest: Well Foundation Property Line \1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> f <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ 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 such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 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 all for all required inspections. Complete drawing on reverse sjde. <br /> Signed X Title: _ — Date: ����" <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ___ Date '� Ares <br /> Pk or Grout Inspection by <br /> i L_— <br /> v Date Final,Inspection by Date <br /> { Additional Comments: �D ri1L� +Z -ice+w r AVS,CJ r <br /> El Stk 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 ElTrac 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH K JI RECEIVED BY DATE PERMIT NO. <br /> ♦.EH 13-241REV.I/N5] <br /> ER 14-2e. <br /> k <br />