Laserfiche WebLink
1 N APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKT_ON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATEkISSUED y"�f:,� .: �,,.• <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 /> d <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 /> City Lot,Si z _ PM <br /> Job Address ` a - <br /> t '�W! i <br /> Address .� Phone <br /> Owner's Name _M "l <br /> 1 Phone <br /> Contractor's Name License No. <br /> WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> TYPE OF WELL/PUMP: NEW WELL E-1SYSTEM REPAIR El <br /> El' <br /> PUMP INSTALLATION SYSTEM <br /> DISPOSAL FLD. PROP. LINE <br /> p� <br /> DISTANCE TO NEAREST: SEPTIC TANK' ! - SEWER LINES <br /> U <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> wc.r_i.!c°i'r.�-......+!.�. _ yam=-•2`^^'s"'.- <br /> 'INTENDED USE"` � TYPE OF"WELL PROBLEM ARFA� -CON$TRL�CTION SPECIFiCAT10N5-` <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing ` <br /> T of Casin Specifications <br /> Domestic/Private ❑ Gravel Pack, ❑ Tracy y g Type of Grout <br /> !❑�ublic ❑ Other I ❑ Delta Depth of Grout Seal yp <br /> El Irrigation <br /> ---Approx. Depth ❑ astern Surface Seal Installed by I v wf <br /> Repair Work Done k Type of Pump <br /> H.P.- <br /> Repair State Work Doneu� L N <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> > <br /> Depth Filler Material {Below 501 <br /> sm <br />'I TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ avlailablelw hin 200 feet.) <br /> permitted <br /> if public sewer is <br /> installation will serve: Residence , Commercial= Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ElType/Mfg Capacity <br /> " Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 5 <br /> Distance io nearest: Well Foundation Property Line <br /> ik Total length/size <br /> h LEACHING LINE ❑ No. & Length of lines property Line <br /> 4 FILTER BED ❑ Distance to nearest: Well Foundation <br /> `I <br /> Number <br /> SEEPAGE PITS ❑ Depth 1A = Size Property Line <br /> SUMPS L1 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS 01 <br /> I hereby certify that 1 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 /> i 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." Y <br /> The applicant must call for all required inspections. Complete drawing on reverse side. r, <br /> Title: Date: <br /> Signed X� x - <br /> FOR DEPARTMENT USE ONLY <br /> Date <br /> � Area D <br /> I Application Accepted by <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by of <br /> Additional Comments: <br /> p <br /> Additional <br /> 46Com ❑ Lodi 369-3621 - ❑-Manteca 823-7104 © Tracy 635-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> CK RECEIVED 8r' DATF. PERMIT"ND: <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO p a <br /> + EH 13-241REV.101831 1 .T <br /> EH 14-28 <br />