Laserfiche WebLink
APPLICATION FOR PE MIT <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. to/,;O <br /> Job Address Z S_5_3 .J` ��'® Aw/ r City t'r Lot Size PM <br /> Owner's Na D�e � Address lS 3 S. 67y'D I V,6- Phone I <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTR N ❑ <br /> PUMP INSTAL N ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE <br /> FOUNDATION A ULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom teca Dia. ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel ❑ Tracy Type of Casi Specifications <br /> ❑ Public ther ❑ Delta Depth of Grout Sea Type of Grout <br /> ❑ I_ �4pprox. Depth ❑ Eastern Surface Seal Installed by 77 <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Wall Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT {No ptic system permitted if public sewer is <br /> table within 200 feet.) t <br /> Installation will serve:;_Residence Commercial_ Other <br /> r <br /> Number of living units: �. Number of bedrooms y + <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 j <br /> SEEPAGE PITS ❑ Depth Size Number ` f <br /> SUMPS ❑ Distance totnearesti -Well' "' 'Foundation'"-'"`� "" Property Line <br /> DISPOSAL PONDS ❑ I <br /> hereby certify that I have prepated 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 California." 1 f <br /> The applicant must call for II required inspections. Complete drawing on r verse side. <br /> Signed6O Title: `^� Date: ZT—P-0 <br /> FORART Ef11T�E ONLY `rl� <br /> Application Accepted by `� Date 0 Area `� <br /> i <br /> Pit or Grout Inspection by i Date Final Inspection by Date <br /> Additional Comments: `. <br /> ❑ Stk 466.6781 ❑ Lodi 369-367K ❑ Manteca 823-7104 - ❑ Tracy 835-8385 _WY <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> + EH1324(REV.s/a5) vy <br /> EH 14-25 0 <br />