Laserfiche WebLink
` I 2_5t—ZOO—( 5: <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 /> I <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 SIAA�ot Size PM <br /> Owner's Name <br /> f f <br /> Contractor Address - License No. Phone <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />[ `❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I l Public Cl Other F Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ _.-Approx, Depth I } Eastern Surface Seal Installed by I <br /> r , <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction Q Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITIO DESTRUCTION 1 1 (No septic system permitted if public sewer is <br /> available within 200 teet.l <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ '� / Method of Disposal <br /> Distance to nearest: Well Foundation J Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: -Well Foundation Oa Ar Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line T <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 D+i'strict. <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 applicant f ed inspections. Complete drawing on reverse side. i r Q <br /> Signed5 <br /> Title: Date- <br /> FOR D <br /> ate:FORD YARTMENT USE ONLY <br /> Application Accepted by t Date AF44A L <br /> -Pit or Grout Inspection by ! ll - Date Final Inspection by VDate <br /> 47 <br /> Additional Comments- <br /> .0 Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2!X19, Stk., CA 95201 <br /> . t <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH13-21(REV.'i/x 51 <br /> EH 11-26 <br />