Laserfiche WebLink
APPLICATION FOR PERMIT i n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> F 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> I Local Health District. <br /> Job Address 5 J SC' d ci S' / r s PM <br /> tY Lot Size <br /> Owner's Name JI MjDA rdla 5 Address aglu5 foo t/c Phone / <br /> Contractor G Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> F-1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. E <br /> FOUNDATION AGRICULTURE WELL ELL PITS/SUMPS . � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ a . Dia. of Well Excavation Dia. of Wel! Casing. <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications /` \ <br /> ❑ Public ❑ Ot ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �4pprox� Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work ❑ Type of Pump <br /> H.P. State Work Done r <br /> Well Dettruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth I Filler Material fBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within"200 feet.) <br /> Installation will serve: Residence Commercial_ Other P <br /> Number of living units: Numbler of bedrooms <br /> Character of soil to ade th of 3 feet: { <br /> Water table depth µ <br /> SEPTIC TANK Type/Mfg Capacity No: Compartments <br /> PKG. TREATMENT PLT" ❑ <br /> III Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> G � � <br /> LEACHING LINE ❑ Nod & Length of lines Tota! length/size <br /> FILTER BED ❑ -.-Distance to nearest: Well Foundation Property Line s <br /> SEEPAGE PITS ❑ Depth f Size <br /> Number <br /> SUMPS.. ❑ Distance to nearest: a: Well Foundation Property Line <br /> DISPOSAL PONDS 1-1 <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." 1 1: <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> igned X <br /> Title: IFY Date: <br /> f+ <br /> FOR DEPARTMENT USE ONLY <br /> D r <br /> Application Accepted by <br /> Date Area <br /> 1 <br /> Pit or Grout Inspection b Date Fina! Inspection by Jl� Date <br /> Additional Comments: ± I <br /> ❑ Stk 466-6781 0 Lode 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return;all copies to: Environmental Health:Permit/Services, 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I <br /> Jf i' <br /> FEE <br /> INFO AMOUNT DUE, AMOUNT REMITTED CK RECEIVED BY <br /> GASH BATE PERMIT NO. <br /> 1+..'.� <br /> + EH 13-24(REV.siesY ��.00) - Li/7,(-,- <br /> �`1'- <br /> EH 1426 1111 J �. tp p 1 _( <br />