Laserfiche WebLink
� 1 <br /> i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> d1 _� 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> N U 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 /> Job Address �� City Lot Size O PM / �} <br /> Owner's Name �JJ�f �!{l/t Address Phone <br /> Contractor ddress License No.�1Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation pprox. Depth ElEastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done A(� <br /> Well Des n ❑ Well Diameter Sealing Material (top 501 �J <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ir REPAIR/ADDITION ❑ DESTRUCTION'❑ (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: --I— Number of bedr ms � <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. ❑ n r Method ofrsDis losif <br /> Distance to nearest: Well /D U Foundation l d Property Line / <br /> LEACHING LINE ❑ No. & Length of lines 3 ! �? Total length/size <br /> FILTER BED ❑ Distance to nearest: Well /d d Foundation !Ir Property Line _ <br /> SEEPAGE PITS ❑ Depth x 10X Q ize Number <br /> _ r � <br /> U <br /> PS ❑ Distance to nearest: Well' Foundation /� Property Line 309 <br /> OSAL PONDS ❑ v <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:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must 11 f r all reqMd inspections. Complete drawing on reverse side. <br /> y / <br /> Signed X / / �f- t�1(;-�I'�-rZC� Title: /''-i Till' <br /> FOR <br /> -�---y^'�— Date: <br /> FOR DEPARTMENT USE ONLY �yy / <br /> Application Accepted , -7 Date //� '6� / , ' Area_J 3-261-07 <br /> �� p <br /> Pit or Grout Inspection y J1� Date "Zf`8i Final Inspection . �/ (by Z� Date Z6 ° ' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835.63851 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 2- <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVN0. <br /> INFO CASH <br /> s <br /> + EH 13-24(REV.1/e 5) -]� ' O� 1/y1f IS g-7_9 9- <br /> EH 14-28 <br />