Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> f Telephone (209) 466-6781 <br /> PERMIT EXPIRES.1 YEAR FROM DATE ISSUED <br /> i (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 Ryles and Regulations of the San Joaquin <br /> Local Health District. ` <br /> /tel l0LA Lot Size PM <br /> Job Address s' D �''� city-- <br /> _ <br /> Owner's Name Address <br /> Ij 7 <br /> Contractor ! t�LG' Address T F3 9 License No.e /6y doh__ Phone r%j;�//,2 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 3 # PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I( DISTANCE�TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALzFj(D. £'ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC I FICATONIS w; <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca . Dia. of Well Excavation Dis. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing r Specifications <br /> ❑ Public ❑ Other t , ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �approx: QepfhY ` El Eastern Surface Seal Installed by aS. <br /> Repair Work Done ❑ Type of Pump H.P. State'Work Done <br /> Well£Destruction ❑ Well Diameter Sealing Material (top 50') <br /> t Depth I Filler Material (Below 501 4' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.)%!, <br /> Installation will serve: Residence Commercials Other <br /> F Number of living units: Number of bedrooms ' <br /> } Character of soil to a depth of 3 feet: 'Water table depth <br /> SEPTIC TANK t� Type/Mfg1 /g_-�F� Capacity %No. Compartments " <br /> 4." PKG TREATMENT PLT. ❑ 4 __ kMethod of Disposal 11' <br /> 4 Distance to nearest: Well Foundation1Prapertyline. <br /> LEACHING LINE ❑ No. & Length of lines T,otal�le gth/size` h <br /> k —FILTER BED '� Distance to nearest: Well�� Foundation 74.` Property Line <br /> SEEPAGE PITS ❑ Depth ! Size - .Number <br /> SUMPS ❑ Distance to nearest: Well 4 Foundation 'i Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thisiapplicationand that the work will be done in acco?dance with San Joaquin county ordinances, state laws, and <br /> i rules and regulations of the San Joaquin, Local Health District. ' }' r 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 /> f !_ - <br /> The applicant must call'for al uire'inspections'Complete drawingon `rever§e side. <br /> i Signed X <br /> Z9 Title: -- Date: <br /> -. P e <br /> t` r FOR DEPARTMENT USE ONLY <br /> °+ Application Accepted by F ^- Ypate �{ Area <br /> '.. Pit or Grout Inspection by Date Final Inspection by ; Dated <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ante.ca 823-7104 ❑Tracy 835-638.5 .i <br /> Applicant- Return all copies to: Environmental Heakh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i f FEE- AMOUNT DUE _AMOUNT"REMITTED`•'"`". -G.K#"" <br /> i INFO w r CASH <br /> .,„-. <br /> + EH 13-24 SREV.t/e 51 <br /> EH 14-26 - O 1 <br />