Laserfiche WebLink
APPLICATION FOR PERMIT <br /> S SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 4666781 <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. t^ <br /> Joh AddressS*� . City Lot Size PM <br /> 23 <br /> Owner's Name �^'� �' `-""K�^ Address 3 ��� Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANq, NEAREST: SEPTIC TANK SEWER LINES AL FLO. PROP. LINE <br /> DATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom anteca Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel P ❑ Tracy Type of Casing Specifications <br /> ❑ Public <br /> or <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> ,, Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> _Installation will serve: Residence_ Commercial— Other <br /> I Number of living units: Number of bedrooms <br /> 1 Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mf C c No. Compartments <br /> i <br /> PKG. TREATMENT PLT. ❑ G: . Method of Disposal } � <br /> Distance to r�eart„ hoe 0 Property Line *� <br /> LEACHING LINE ❑ No. & Leng E,' 16� ��m I Total length/size <br /> FILTER BED ❑ Distance to nr�T �} 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, 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 applicant must call for all required in ctions Complete drawing on averse sides. ,� 9 <br /> r �.v f <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � Area <br /> ep m I fi )1W wi t c 7bh Date <br /> Pit or Grout Inspection by r'} Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 8354085 <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 CK RECEIVED BY, DATE PERMIT'NO. <br /> INFO <br /> + EH 1324{REV�Ia51 �5 . 111Z` g �T7-57Q <br /> EH 1428 <br />