Laserfiche WebLink
4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) �ttijm d � <br /> k ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t war h escribed. 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 PM j <br /> Owner's Name U0 txelr 4, y"+ To V/*O�Address �t Phone <br /> frmrtmrSe+; � Address License No. 1211A Phone Yeoy r4 ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE ELL PROBLEM AR TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom an a ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gr ack ❑ Tracy Type of Casing Specifications j <br /> f'l Public Other Ll belta Depth of Grout Seal Grout <br /> I Irrigation _-Approx. Depth I I 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 50') <br /> Depth Filler Material (Below 501 i <br /> TYPE OF SEPTIC WORK: NEWiMTALLATION I 1 REPAMIADDITION l 1 DESTRUCTI 1 INo septic system permitted if public sewer is I <br /> i available within 200 feet.) <br /> Installation will serve: ResidenceCommercial— Other <br /> Number of living units: Number of bedrooms G <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 /> E i <br /> Distance to nearest: Well Foundation Property Line <br /> c i <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlsizef <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property tine <br /> i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L-1 Distance to neare4:_,,,,,,_Well. yFoundation 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 Di%trict. i <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." <br /> The apgkof'if-rust call for all required ' ctions. Complete drawing on reverse side. <br /> SignedCCX Title: +� Date: �r <br /> FOR DEPARTMENT USE ONLY l <br /> Application Accepted by Date Area j <br /> Pit or Grout Inspection b Date Final Inspection by Date <br /> Additional Comments: <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 95201 <br /> t s N <br /> FEfAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> y / <br /> +.EH 13-21(REV. /n s) !/ 1^Z <br /> EH 1A-2t3 � ! I <br />