Laserfiche WebLink
�d ti o APPLICATION FOR PERMIT r <br /> SAN JOAQUI <br /> - N LOCAL HEALTH DISTRICT <br /> �J 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 1 <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. 18M for well/pump and the Rules and Regulations of the San Joaquin - <br /> Local Health District.�./ � � / C �� ��r�/� {C � �/ ' <br /> Job Address _ ` fl Or-a Z ( y Z n city r Lot Size <br /> PM <br /> Owner's Name .��L 1 (/ �p/-Q_ Address �- - <br /> f '-T ` Phone- - <br /> ContractorAddress «C y.v * <br /> License No. 2 Phone Z f <br /> TYPE OF WE!!/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION p SYSTEM REPAIR ❑ OTHER ❑ o <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.f a' PROP. LINE <br /> FOUNDATION r" <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA .CONSTRUCTION SPECIFICA 1 NS � <br /> Ilk <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati p ` �� � <br /> / Dia. of Well Casing [+ 0, <br /> Domestic/Private Gravel Pack Tracy Type of Casing Specifications f a�fJT <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal / <br /> ElIrrigation f�— p Jl�, `TYPe of Grout f'� r� <br /> / Approx. Depth ❑ Eastern Surface Seat Installed by bpi •o <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) o <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system <br /> � permitted if public sewer is <br /> Installation will serve: Residence_ Commercial available within 200 feet.) <br /> — Other <br /> Number of living units: Number of bedrooms L <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 11Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method of Disposal <br /> 1 <br /> Distance to nearest: Well Foundation Property Line , <br /> r � <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> t <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well 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. <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 laws of Califo nia." <br /> The applic m tali for II r u' d inspections. Complete drawing on side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 8 <br /> Pit or Grout Inspection by Date A=A�_ Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY / DATE yPERM1T <br /> + EH 14-24(REV.i/as) •{f-1 �y h1¢ rl } <br /> EH 14-28 <br />