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 /> i Local Health District. f <br /> Job Address 2--r Cit yJ Lot Size PM <br /> U IF <br /> Owner's Name <br /> Address <br /> Contractor Address ~1 A" > 4 * License No.g�!"Sg_'`:�5QAPhone`Z3�'9 <br /> -1A0C1' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE <br /> FOUNDATION AGRICULTURE WELL.' OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public D Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I Irrigation €..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump _ H,P. State Work Done \ 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') p <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK:' NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> 4 available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other { <br /> Number of living units: ' Number of bedrooms r j <br /> Character of soil to a depth of 3 feet: Water table depth - <br /> SEPTIC TANK F] Type/Mfg Capacity -No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> f <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> • M <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Ll Distance to nearest: Wella Foundation Property Line <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 District. 1 <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: 1 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 must call all required inspections. Complete drawing on reverse side. <br /> Signed X-%19,, •=- ' <br /> Title: wl//�'+��G., Date: <br /> FOR DEPARTMENT USE ONLY 2 <br /> Application Accepted by Date �9 tea <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> 1 <br /> ❑ Stk 466-6781 El Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT"NO. <br /> �+ EH 13-24{REV.t i w 51 <br /> EH t4-ZB � <br /> _ '" <br />