Laserfiche WebLink
A <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. i 11 <br /> Job Address Q4,503 S City Lot Size /a' ¢4 PM <br /> Owner's Name �+ <br /> Address I_-79 .- 1121 ota i Q _ Phone <br /> Contractor's Name License No. 37:7339 Phone �6 7-016 <br /> I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br />- - , <br /> -DISTANCE_TQ NEAREST; SEPTfC_TANKF SEWER,LINI S..-.DISPOSAL.FLD. PROP. LINE <br /> FOUNDATION 4'-1- AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 0 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout SealT 09 <br /> - ype of Grout <br /> ❑ Irrigation <br /> --Approx. Depth ❑ Easter aSurface Seal Installed by- Iw <br /> Repair Work Done ED Type of Pump H.R. State Work Done <br /> Well Destruction ❑ Well Diameter I Sealing Material-atop 50') <br /> Depth Filler Mateiial'IBelow 50') { <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION +REPAIR/ADDITION ❑ DESTRUCTION ❑,Mo septic system.perm itted if public sewer is <br /> i available within 200 feet.), <br /> Installation will serve: Residence Commercial Other's"""'""'" <br /> Number of living units:_._t— Numberofbedrooms __ { <br /> ..;'Character of soil to a depth of 3 feet: 1. i Water table depth 7 p <br /> SEPTIC TANK ❑ Type/Mfg Capacity�� No. Compartments <br /> PKG . TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Fopndation Property Line <br /> LEACHING LINE Cfi' No. & Length of lines - <br /> Total length/size }c �•5 � <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ , Depth •+Size Number <br /> SUMPSLr—Distance to nearest: &Well__,3'�_Foundation D __P_ro _ <br /> DISPOSAL PONDS ❑ i <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 n <br /> rules and regulations of the San Joaquin Local Health District. 9~- :- <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: "1 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 appli nt must call for I requ'ed inspections. Complete drawing on reverse side. <br /> Signed' <br /> Title: Date: { <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by + Date / Area ©7 <br /> Pit or Grout Inspection by Date �+tCFinal Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTER RECEIVED BY DATE PERMIT°N0. <br /> +EH 1324(REV.10183) <br />- - EH 14-26 II lys1.3 <br />