Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ii <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 /> 'f PM <br /> i City Lot Size <br /> Job Address 7 ,&?�? � &( <br /> r dress _, �!�?— 4 Phone <br /> Ad <br /> Owner's Name e ti y <br /> Contractor's Nam <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST::SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE`)F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 10 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Specifications <br /> El Domestic/ of Casin Domestic/Private F1 Gravel Pack ❑ Tracy g <br /> Ll <br /> Type of Grout <br /> Public s❑ 13Other Delta .,,Depth of Grout Seal <br /> ❑ Irrigation _JAppro Deptii ❑ Eastern Surface Seal Installed by m� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> 1 Sealing Material (top <br /> Well Destruction El Well Diameter i5 <br /> f <br /> Depth Filler Material (Bel 50'i <br /> ( OF <br /> TYPE SEPTIC WORK: NEW INSTALLA N ❑ ..REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> F available within 200 feet.) <br /> ' f <br /> Installation will serve: R dance Commercial— Other <br /> Number of living units: Number of bedrooms ' _ <br /> Character of soil to a.depth of 3.feet: j `'Water table depth <br /> SEPTIC TANK ❑ ,Type/Mfg, ani Capacity No. Compartments <br /> k > ` <br /> PKG. TREATMENT PLT. E] Method of Disposal <br /> i Distance to nearest: Well Foundation Property Line <br /> L <br /> LEACHING LINE [--1No.1& Length`of'lines Total length/size <br /> g _ Pro a Line <br /> ILTER BED ❑ .Distance to nearest: .Weil? Foundation P rtY <br /> SEEPAGE PITS ❑ Depth 1 Size NumberA <br /> SUMPS ❑ Distance,to.Ye rest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - { <br /> i.. <br /> Thereby 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 cer4ibs 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 Califomia.' Contractor's hiring or sub contracting signature <br /> lcertifies 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 /> he applicant must call for a ired inspecti_o .Complete drawing on reverse side. <br /> I 'Title: Date: y <br /> Signed 4 <br /> ` FOR DEPARTMENT USE ONLY <br /> t <br /> Application.Accepted by f Date Area <br /> .Pit or Grout Inspection by .. <br /> Date Final Inspection by Date <br /> 'Additional Corriments:�` - <br /> ❑ Stk 466-67$1 ❑ Lodi 369 3621 O>Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Rewm all copies to: Environmental Health Permit/Servioss 1601 E. Hazelton Ave., P.O. Box 2009, Stk. CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +Eu 1&2a[NEV.10/931 <br /> EH 1426 <br />