Laserfiche WebLink
APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 11 , 9 (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 H 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 ,ire:�'� .t1 :R'f :g a 3"=. - <br /> Job Addre§s ' . <br /> City . Lot Size PM <br /> Owner's Name T Address - <br /> !\, �L r ­-Address,—) <br /> —=g �T Phone t <br /> Contractor. Address <br /> 4�— /eT' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION-El-- SYSTEM REPAIR ❑ OTHER ❑' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` <br /> D15POSAL FLD. PROP. LINE <br /> FOUNDATION' AGRICULTURE WELL - ` OTHER WELL PITS/SUMPS <br /> INTENDED USE _„-TYPE-OF.-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 17Domestic/Private EJGravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> LJ Public EJ Other Specifications <br /> ❑ delta Depth of Grout Seal <br /> Cl Irrigation Type of Grout <br /> ---Approx. ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H P <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 501.' c� r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTIO mo septic system permitted if public sewer is o` <br /> Installation will serve: Residence_ Commercial�s Other vailable within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: `_ .` A-N <br /> SEPTIC TANK Water table depth r <br /> Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT. [I y <br /> Method of Disposal r <br /> -+ Distance to nearest: Well i. Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines w <br /> FILTER BEDTota! length/size <br /> 1 ❑r Distance to nearest: Well Foundation � Property Line <br /> SEEPAGE PITS O Depth Size <br /> Number <br /> SUMPS ., <br /> .❑ Distance to.nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> --------------------- <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 whic <br /> tion laws of California." h this permit is issued, I shall employ persons subject to workman's compensa- <br /> ` <br /> The applic t ust call for all a ed insp­ -�� <br /> q pecti n Complete drawing on reverse <br /> side- <br /> Signed X <br /> Title: _2 T <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C s <br /> Date O Area <br /> Pit or Grout fnspeVtionDate Final Ins pection byDateAdditional comm <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 Manteca 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 /> AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY' DATE PERMIT'NO. <br /> + EH 13-24(REV.tins} <br /> EH 1428 <br />