Laserfiche WebLink
} <br /> i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> { Telephone {2091 466-6781 <br /> x PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 00 <br /> ef, (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 N 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> 6 <br /> Local Health District- ;r SC /Y1 ' `i A/.t <br /> Job Address City �/� Lot Size PM <br /> Owner's Name Address �] /�� <br /> ✓ _✓ Phone <br /> Contractor d►�t/ Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM T ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION (71SYSTEM R AIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> p FOUNDATION GRICULTURE W/L — OTHER WELL PITS/SUMPS _ <br /> I INTENDED USE _TYPE OF WELL PROBLEM A C STRUCTION SPECIFICATIONS _ <br /> Ll Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation­ – �' Dia. f Well Casing J <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T of Casing— ' <br /> Specific <br /> f 1 Public n Other (-1 Delta Depth rout Seat Type of'Grout--- <br /> I I Irrigation -Apprax:Depth l I Eastern Surface Sea stalled by <br /> Repair Work Done LI Type of Pump H.P. State Work Done_ <br /> t Well Destruction E3 Well Oiameter Sealing Material (top 501 j <br /> Depth 1 Ffl�le Material (Below 50'1 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i I DESTRUCTION Psj Wo septic system permitted if public sewer is <br /> available within 200 feet.) r <br /> Installation will serve;: Residence_ Commercial—�Otth <br /> er <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:1 Water table depth <br /> SEPTIC TANK I <br /> Ll Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line � rj <br /> 1 <br /> { <br /> LEACHING LINE ❑ No. & Length of fines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I'] Depth Size ; Number <br /> SUMPS ❑ Distance to nearest: Wella #Foundation Property Line <br /> DISPOSAL PONOS 171 t I, t r <br /> I hereby certify that I have prepared this application land that the wor"ll be done in accordance with San Joaquin county', rdinances, state laws, and i <br /> rules and regulations of the San Joaquin Local Health District. 1 <br /> Home owner or licensed agent's signature certifies the foilowing:.::f-certify that in the performance of the work for which this permit is issued, !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 alifornia. <br /> The applican must call for all required inspections- Complete drawing on reverse side, 3 <br /> � 1 <br /> Signed X Title: Date: <br /> FOR-DEPART NT,USF-ONLY <br /> Applica ran Accepted by Date_ 21L�� Area <br /> Pit or Grout Inspection by 'k. f Date Final Inspection by �/ _ ie' D e <br /> Additional Comments: i} AA?�; *, <br /> 10 <br /> ❑ Stk 466-6761 0 Lodi 369-3621 ❑ 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 /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE MPERMIT'NO. <br /> INFO � ,EH114-24rRev., rss, S Z$`7 <br /> EH 14-28 <br />