Laserfiche WebLink
i <br /> APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T 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 /> Job Address Z42 /� � wzefe - City .� F Lot Size PM <br /> Owner's Nam /Odress T Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _OT} ERC ! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS D:f PROP. ,LINE. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Q Open Bottom ❑ a eca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI PubGc Ot ~k n Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation Approx. Depth I i Eastern Surface Seal installed by - <br /> <Repai �truction�LJ <br /> Type of Pump H.P. State Work Done_ <br /> Wel Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material {Below 50') Itvv <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ( 1 DESTRUCTIONA INo septic system permitted if public sewer is <br /> _ <br /> ' available within 100 feet.) <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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED. ❑ Distance-to nearest: Well Foundation Property Line <br /> SEEPAGE PITS�h'. . I I pth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 of sub-contracting signature <br /> certifies the following: "I certify that in the pe'rfoFniancd of the work far"which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." " <br /> 'cant must call for all required ins ctio Complete drawing on reverse side. <br /> (Signed X �, --F Title: si ,.e o�.i/' Date: /� 7 <br /> FOR DEPARTMENT USE ONLY <br /> 0 i <br /> Application Accep;e7 <br /> Date r/ "� rea 1 rr <br /> z 7 0 <br /> Pit or Grout Inspe Date Final Inspection b Date <br /> / t <br /> Additional Comments: ✓E '� { f r '+J I-(` VIP(- <br /> 0 Stk .466-6781 ❑ Lodi 369-3621 ❑.Manteca 823-7104-- .• ❑ Tracy -6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 13Y DATE +PPEERMIT*NO. <br /> + EH'13-241F1Ev.I/KS) <br /> EH 14-28 _✓� - <br />