Laserfiche WebLink
5 <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 /> d (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. 1, <br /> } { 1 r ty Lot Size PM h <br /> t. Job Address <br /> Owner's Name - Address — _ — Phone <br /> ense No, Phone <br /> Contractor's Name - - - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ElSYSTEM REPAIR ElOTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK( SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION! AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack F-1 Tracy— ^——Type.of,Casino Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation 1---Aj ❑ Eastern .� Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter f Sealing Material (top 501 I J <br /> Depth j Filler Material (Below r LA <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> R available within 200 feet.) <br /> installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms •3 .--- <br /> Character of soil to a deptt f 3 feet- j Water table depth <br /> SEPTIC TANK 1> �# +Ype/Mfg { Capacity No. Compartment <br /> s <br /> t Method o 1 sal <br /> PKG. TREATMENT PLT. ❑ 1 <br /> Distance to nearest: "Well Foundation — Property Line <br /> Total len th/size <br /> LEACHING LINE ` ❑ No. & Length of lines '- g <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <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, a <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 applicant o required-iris ections. Complete rawing on re e side. rr <br /> ( [r <br /> Title: Date: <br /> Signed <br /> .t FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date re <br />' Pit or Grout inspection by Date Final Inspecti n by Date <br /> i Additional Comments: <br /> ❑ Stk 466-6781 C3 Lodi 3621 EJ Manteca 823-7104 ❑ Tracy 835 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I . <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> + EH 1324 TREY.101931 <br /> EH 1429 <br /> f <br />