Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—i ON AVE., STOCKTON, CA <br /> 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 /> SI <br /> SS- 1 ) �- - <br /> Jab Address :__ City � Lot Size PM <br /> F <br /> Owner Name Address rr7 i li i t3�t� F Phone <br /> h <br /> Contractor ddress License No. Phone � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWLINES DISPO F. PROP. LINE <br /> FOUNDATION AGRICU URE WELL ER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRU N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe.o asing Specifications 1 <br /> ❑ Public ❑ Other ❑ Delta Depth of G ut Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Easte Surface Seal i alled by �nn <br /> Repair Work Done ❑ Type of Pump AREA <br /> State Work Done_ V' <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 �M <br /> Depth Filler Material (Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 206 feet.) <br /> Installation will serve: Residence— Commercial T Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth P I <br /> SEPTIC TANK ❑ Type/Mfg Capacity N ompartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: II Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of,.lines Total length/size <br /> f FILTER BED ❑ Distance to'nearest: W ndation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Dista o nearest: Well Foundation 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 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."Contractors 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 a t must call for all required inspections. Complete drawing on reverse side. [ <br /> Sig d X Title: Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted b Date cam'U"92 Area <br /> 6Z <br /> I <br /> Pit or Grout Inspecti Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ ganteca 823-7104 ❑ Tray 835-MM ti <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> i <br /> + EH 13.24(IIEV.1/a 5) <br /> EH 14.26 Com. O a �^�!1 , <br /> �1 27 <br /> J <br /> d <br />