Laserfiche WebLink
APPLICATION FOR PERMIT <br /> "SAN JOAQUIWLOCAL:HEALTH DISTRICT <br /> '1601 E. HAZEL} ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ¢ . <br /> "PERMIT EXPIRES1 YEAR FROM DATE ISSUED_ n <br /> _(Corr piete 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 o.549 for sewage or No:1862 for well/pump and the Rules and Regulations of the San Joaquin ) <br /> Local Health District. S" 10 3 f <br /> Call G j�,ti i <br /> Job Address City Lot Size PM_ 1 <br /> 9 <br /> Owner's Name _ Address Phone <br /> Contractor's Name License No. `��� 2� Phone <br /> TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPA16- P— 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"1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_`" ` Dia, of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing .•' „Specifications <br /> ❑ Public v ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Ll Irrigation Approx. Depth Eastern Surface Seal Installed by ' <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done' <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 4. 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. ❑ - ;'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 ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property line <br /> DISPOSAL PONDS ❑ <br /> 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:"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." r <br /> The applicant ust it fII required inspections. Complete drawing on r 1 a side. <br /> Signed X / Title: date: <br /> FOR PARTMENT USE ONLY a <br /> Application Accepted by V Date � Area Y <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: Y 40 <br /> — — <br /> ❑ Stk 466-6781 ❑ Lodi -369-3621 ❑ 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 852(11 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. <br /> + EH 13-24(REV.10!891 <br /> EH 1425 .S.. t']Qr7 '` •7�� �� �° - <br /> i � � <br />