Laserfiche WebLink
f Y <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 hepeby 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 /> I Job Address/'77d �' � , /�, <br /> City - Lot Size�'"��-�-c� PM <br /> Owner's Name Address <br /> Phone <br /> Contra <br /> c �L/` Address � License No ZZ hon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r <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 ❑ Tracy Type of Casing Specifications <br /> I'1 Public [71 Other 71 Delta Depth of Grout Seal Type of Grout--­ <br /> I <br /> rout _I I Irrigation --Approx. Depth i I 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 r Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ DDITIOM DES <br /> TRUCTIDN E I (No septic system permitted if public sewer is <br /> t s , available within 200 feet.) <br /> Installation will serve Residence. Commercial Cher <br /> Number of living units: --L Number of belooms <br /> Character of soil to a depth-of•3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity. ''No. Compartments p <br /> PKG. TREATMENT PLT. ❑ `} Method of Disposal <br /> Distance to nearest: .Well Foundation ' Property Line <br /> LEACHING LINE .No. & Length of lines'. f Total lengfh/siz <br /> FILTER BED ❑ Foundation — t I <br /> Distance to nearest: Well� Property Lini- e <br /> e <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L7 Distance to nearest: <br /> Welf Foundation Property Line <br /> DISPOSAL PONDS Ll <br /> I hereby certify that I have prepared this application arid 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 /> - k <br /> i <br /> The applicant u call for uir ' inspections. Complete drawing on reverU <br /> i (l�� QUA <br /> Signed X Title: l, Date: K.i L4� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> r <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2049, Stk., CA 95201 I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH DATE PERMI7'NO. <br /> + EH 13-24(REV.iin51 <br /> EH 14-28 � Ir 2 � <br />