Laserfiche WebLink
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 /> (Complete in Triplicate) <br /> y 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 /> �. ../� <br /> Job Address � lS�.C] A <br /> ---�— �_ City G of Size PM <br /> Owner's Name �IVYtb:sK Addresst.,. j` <br /> '" x r Phone <br /> Contractor 1�—� �`� s.�, Q r//4 <br /> Address License No. 477 4D <br /> TYPE OF WELL/PUMP:.. Phone_ <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> f DISTANCE TO NEAREST: SEPTIC TANK OTHER Q <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLi, <br /> PITS/SUMPS ✓� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> .❑ Domestic/Private Dia: of Well Casing <br /> ❑ Gravel Pack ❑ Tracy Type of Casing �- <br /> i� Public ❑ Other Specifications` <br /> CD Delta Depth of Grout Seal Type of Grout <br /> I I Irritlation ­Approx. Depth I 1 Eastern Surface Seal Installed by,^ w <br /> Repair Work Done LJ Type of Pump t <br /> H.P. i Stat Work Done <br /> Well destruction ❑ Well Diameter r Sealing Material Itop'S0'1 <br /> Depth Filler Material (Below 50'1 1w., <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ClY REPAIR/ADDITION i I DESTRFJCTIDN !No septic system permitted if public7sew7eris t <br /> Installation will serve: Residence_ Commercial_ Other variable within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: --- ^-- -� <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: WeII Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Total length/size <br /> Property Line , <br /> SEEPAGE PITS I I Depth Size <br /> SUMPS Number <br /> L� Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation Property Line <br /> 1 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."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 law lifornia." <br /> The app cat st calf a r wired inspections. Complete drawing on reverse side. <br /> Signed X Title: ` Cx 2--222-48 <br /> ��ruLC�IJik. Date: f <br /> -_FOR.DEPARTMENT•USE-ONLY,-- <br /> Application Accepted by -� x;� •- f .. <br /> Area ± <br /> Pit or Grout lnspection by- �.. Date <br /> �- - — _ <br /> .,Fina/ Inspection by fate r< 6 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-362-71 &0 Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f^ <br /> E <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMFT'NO. <br /> t EH 13-24 MEV.iEH 14-28 <br /> ia <br /> ti �S <br />