Laserfiche WebLink
t <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 thwSan Joaquin <br /> i Local Health District.. <br />` Job Address/ ��i /Vr City Lot Size PM <br /> Owner's Name Address Phone <br /> 10 <br /> y i <br /> ContractF r . r . ` Address <br /> License No. 2Z&Phon - <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 FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 14- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation _ <br /> Dia. of Well Casing . <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing g <br /> i'1 Public Specifications <br /> f] Other C1 pelta, 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 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> .- Depth er Material (Below 501 r r <br /> TYPE OF"SEPTIC WORK: 'NEW INSTALLATION I REPAIR ADDITIO DESTRUCTION i I (No"septic'system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will-serve: Residence X Commercial_ Other J <br /> Number of livin units: Number of r b !� <br /> 9 � voms T . <br /> Character of soil to adepth of 3 feet: wr, <br /> Water.table depth /L <br /> SEPTIC TANK ❑,f Type/Mfg. <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑_�., <br /> Method of Disposal <br /> --- --- � / Distance to nearest; Well Foundation Propdy rtLine <br /> f' « <br /> ,LEACHING LINE— +_.._❑T'No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Welt ;' <br /> ! Foundation Property Line 1 <br /> -SEEPAGE PITS . Depth Size _ Number <br /> SUMPS—"", L1 Distance to nearest: Well <br /> - 1 <�-;/Gx/— -Property,Cine <br /> DISPOSAL PONDS ❑ \ �- �, � <br /> -I hereby certify that I have.prepared tliis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> by rules and regulations of the San Joaquin Local Health Di'%trict. <br /> z .1`" Hortfe owner•or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall not t <br /> empf es the person in <br /> such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> following:certi "I certify that in the performance of the work-for which this-permit.is issued,f shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mcall for aled inspections. Complete diawing on, <br /> reverse d <br /> Signed X - — _ —T(tle: <br /> Dater I <br /> FOR DEPARTMENT USE ONLY i <br /> Application Accepted by Date Area/, <br /> ( or Grout Inspection by atr, <br /> _/ Final Inspection•by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED <br /> ED BY DATE PERMIT-NO. <br /> +.EH13-241REV.siHis) n ' <br /> EH 14-28 fvf J ` <br />