Laserfiche WebLink
AJO <br /> APPLICATION FOR PERMIT AJ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA 5 <br /> Telephone (209) 466-6781 <br /> e <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. 1862 for well/pump-and the Rules and Regulations of the San Joaquin <br /> Local Health District: - <br /> Job Address T fO 3 �-- �e �1'1 City J „ + Lot Size S� PM <br /> ' Owner's Nam Address a " Phone -,16 'S z 7 <br /> %f2 bQ tdx-� <br /> Contractor Address7 � � <br /> _ �� License Na.��{v �c� 7 Phone � � 9 ) <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' # <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> E 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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 Yell <br /> ❑ Irrigation ---Approx. Depth C❑ 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 501 <br /> Depth ' Filler Material fBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ESTRUCTION (N septic system permitted if public sewer is <br /> li vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms y►. �" -- <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ T e/Mf <br /> YP 9 Capacity— <br /> _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Tota! length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 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 ust all for all required inspectio s. Comps to drawing on reverse side. <br /> Signed XTitle'. �17 — a T Date: �Qr <br /> x r <br /> FOR I?EPARTMENT USE ONLY `] <br /> Application Acceptedby Date` G ` Area <br /> Pit or Grout Inspectio Date Final Inspection b Dat <br /> Additional Comments: <br /> ' ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑,Tracy 835-638.5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO CASIT <br /> ' ; EH 1428(R".t/esl '� 5-77--Sl -_ w <br />