Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> t N4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> k 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. A <br /> Job Address f R City Lot Size <br /> Owner's Name Address W `� Phone J— <br /> Contractor's Name -&,4License No. z 79 Phone <br /> TYPE OF WELL/PUMP:" NEW WELL,El WELL REPLACEMEINIT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑" SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6 DISPOSAL FLO. 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 /> El Domestic/Private ❑ Gravel Pack _ .0,TracyType of Casing Specifications <br /> ❑ Public �'�L❑ Other -1 Delta 1 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 Materialw(top 50') <br /> Depth i _ 'Filler Material j Below 50'1 _ § <br /> TYPE-OF-SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑j tDESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial i Other <br /> r <br /> Number of living units: 4 Number of bedrooms <br /> Character of soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> i <br /> Distance to nearest: well /00 Foundation Property Line <br /> r - <br /> LEACHING LINE ❑ No. & Length of lines !a Total length/size )w <br /> FILTER,BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size 3 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 for q requinspections. Co plate drawing on reverse side. y <br /> f Signed I Title: M—,2 Date: h1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ,�,� Date Area d <br /> Pit or Grout Inspection by Date Final Inspection by 4­ Date��Y3 <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. <br /> +EH 1324 IREV.141831 <br /> EH 1425 <br />