Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ES <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> -?I ,-.,. '•L-Iit olc(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'Couhty Ordihance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. ;. <br /> / .SxPM <br /> Job Address <br /> city �� Lot Size— <br /> Owner's Named C� rC j C-4 I4C'� Address <br /> cs v Phone 6 5 f <br /> Aaz r= <br /> Contractor 4 Address_9�? � ! License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK S LINES D <br /> ISAL FLD. PROP. LINE <br /> FOUNDATION AGRICU URE WELL WELL PITS/SUMPS <br /> h <br /> INTENDED USE STYPE OF WELL PROBLEM AREA ONSTRU N SPECIFICATIONS <br /> ❑ Industrial d Open Bottom ❑ Manteca D . o ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private L] Gravel Pack ❑ Tracy f Casing Specifications <br /> d Public El Other ❑ Delta Depth Grout Seal Type of Grout <br /> ❑ irrigation �Pprox. Depth ❑ Eastern Surface S I Installed by <br /> Repair Work Done ❑ T;ype of Pump �. H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> `Depth filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No 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 /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Cl; Type/Mfg Capacity No. Compartments <br /> I <br /> PKG. TREATMENT PLT. © Method of Disposal' <br /> Distance to nearest: Well Foundation Property Line <br /> ` Total length/size <br /> LEACHING LINE 0 No. & Length of lines 1 <br /> FILTER SED 0 Distance to nearest: Well Foundation Property Line <br />` SEEPAGE PITS D Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Q <br /> hereby certify that I have3Prepared 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: "!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 subcontracting 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 /> I tion laws of California." , <br /> IE plic m t call for all required inspections. Complete drawing on reverse side. <br /> Signed ^ ` Title: .Date: <br /> FO DEPARTMENT USE ONLY k_4 ' <br /> t r� Area c/ <br /> j Application Accepted by Date <br />! Date Final Inspection by -� Date�� <br /> Pit or Grout Inspection by _ <br /> Additional Comments. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑.Manteca 823-7104 ❑Tracy 83 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. He Ave., P.Q. Box 2009, Stk., CA 95201 <br /> f <br /> FEE. AMOUNT DUE AMOUNT9EMiTTEA l RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> C 003-3-P7 P7- yy-7 <br /> + EH 1324(REV.1/e 5) �J v '�"-� <br /> EH 1428 <br /> 1 <br />