Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUtN LOCAL HEALTH DISTRICT <br /> �T�N AVE., STOCKTON, CA <br /> 1601 E. HAZE <br /> Z� Telephone (209) 466-6781 <br /> PERMIT EXPIRE$ 1 YEAR FRQM,OATE 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 7 �• �� City ' Lot Size PM <br /> Owner's Name�� Address Phone <br /> Contract4Q AddressLicense No. Phone <br /> TYPE OF WELL/PUMPf NEW WELL ❑ WELL REPLACEMENT ❑ DEST CTION ❑ <br /> U • yF JNIP INSTALLATION ❑ S'YSTEM-REPAIR-❑ OTHER ❑ <br /> L L <br /> ANCETRE$T S6pT1C TANK SEWER Ltf+JES �-..�� AL :-sE 0060. LINE <br /> FOUNDATION AGRICULTUREWELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public 0 Other. 0 Delta Depth of Grout Seal Type of Grout <br /> ❑Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work,Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top.501 <br /> Depth Material`IBelow 501 <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ DDITION E C ,ON ❑ <br /> (No4spW system,permitted if public sewer is <br /> avada inrithin200 feet,) <br /> Installation will serve: Residence v Commercial they <br /> Number of living units: Number of Dome J <br /> Character of soil to a depth of 3 feet:s = CJ f. Water table depth SI <br /> SEPTIC TANK ❑ Type/Mfg Capacity NQ-Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well FoundatiorF%' Property Line <br /> LEACHING LINE ❑ No. &.Length of lines Total length/sizeL <br /> FILTER BED ❑ Distance to nearest: Well Poundiffon, Property.-Cine ; <br /> SEEPAGE PITS %' Depth e'• Number <br /> SUMPS Q Distance ta•r>aar t: Well fourrf'twY-12:-: <br /> DISPOSAL PONDS ❑ � R <br /> I hereby certify that I have prepared this application and that the worTc will be done in accordance with Sen Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agents 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 mangler 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 i's+astted,I sh aff ploy persons subject to workman`s compensa- <br /> tion laws of California." <br /> The applicant call for inspectrogs. Complete drawjpg ontsxe <br /> 7 <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by v ;Dste � <br /> it Grout I ort by ate 7 % Final inspection by, • n Date <br /> dditionai Comments: <br /> Stk 468-ti 1 -❑ Manteca W3-7104 ❑ Tracy 8354 <br /> Applicant-Return all copies to: Environmental Health Permit/Servkes 1601 E. Hazelton Ave., P.O. Box 2008,Stk., CA 95301 <br /> IEEE AMOUNT DUE AMOUNT REMITTED C$H - RECEIVED 8Y DATE PERMIT NO. <br /> NFO <br /> + EH 13-21(REVS/w5) I <br /> EH 11-28 <br /> i <br />