Laserfiche WebLink
1 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> r_ <br /> Job AddressCity Lot Size U _ PM <br /> n j / <br /> �J !!'']] ��[[ <br /> Owner's Name._ `/!',P.l�> Address �� �' n^'r- Phone ` Zv���" <br /> Contractor r S 4 l /V �� License NYf s Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION:❑ <br /> -r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. �- PROP. LINE <br /> W: '*FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEOIFICATIONS <br /> ❑-IInndustwial Y ED Open Bottom ❑ Manteca Dia. of W611�Ezcaiaiion Dia-of Well Casing � <br /> ❑ Domestic/Private'' ❑ Gravel Pack �, ❑ Tracy Type of Casing Specifications <br /> j ❑ Public n Other ❑ Delta Depth of Grout Seal 'Type of Grout _ <br /> I Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by <br /> f --- <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 lgelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW 1NSTALLAZON l REPAIR/A_!)DiTION I] DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms 2marts Y` ' <br /> Character of soil to a depth of 3 feet: �. Water table depth (t <br /> SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments (,1+ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: WeIIC_L Foundation / Property Line 74 <br /> n <br /> LEACHING LINE 0 No. & Length of linesS Total length//size' * - - - <br /> FILTER BED ❑ Distance to nearest: Well Foundation-�' ' Propeirty`Line <br /> t <br /> SEEPAGE PITS , FF Ill Depth Size ''Number 7, <br /> SUMPS a CD Distance to neare : Well /S 0 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 /> Homeowner 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 /> 1 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 <br /> The applicant ust call for all quire in ctions. Complete drawing on reverse side. . <br /> Signed X Title: Date: <br /> NL <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by -, Date Area �'�� 3 _ <br /> Pit or Grout Inspection by Date Final Inspection by �J Date 2 <br /> Additional Comments: t/J � C7� `b` f2,- � 2 <br /> ❑ Stk 466-6781 ❑ 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 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED [CASH RECEIVED BY 0ATE �PQERMIT'NO. <br /> a EH 13-24(REV.1�/,y5) <br /> EH 1426 <br /> i' •"4 <br />