Laserfiche WebLink
APPLICATION-FOR PERMIT <br /> 1 .SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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." <br /> /Job Address r U S City. Lot Size ��'a/x , PM <br /> Owner's Name �U 'yY Alvzc �� Address PV2 ��N�=�L Phone 33� <br /> Contractor �L�l Address License No, Phone <br /> k TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j <br /> DISTANCE TO NEARE C TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE RUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ElManteca Dia. of Well Excav Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications } <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Typ rout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by l{ <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 <br /> x TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION)EQNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> l LEACHING LINE ❑" No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑«. Depth Size Number �f <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 California <br /> '. The applica mut all for 1��tions. Complete drawing on reverse side. � <br /> Sighed X Title: Date: <br /> FOR DEPARTMENT USE ONLY G <br /> Application Accepted by Date / Area <br /> Pit or Grout Inspection by Date Final Inspection by Date Z <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy- 835-6385 <br /> 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> w <br /> FEE <br /> 1 INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. <br /> : {�Sa0H <br /> EH 418 <br /> a EH 13-24(REV.1/n 5t• V�I e � �� lJ aa- <br /> 1 <br />