Laserfiche WebLink
i <br /> APPLICATION FOR PERMIT <br /> } SAN JOAQUIN LOCALfHEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA a �'Q J/1_r <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 /> / Joh Address ��p� G _ Sbll 0 12 _� City Lot Size PM i <br /> / Owner's Name M_ 11 Address (0 G FS4 ho a,+ Phone '46d 41 <br /> ContractorJU. t Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 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 I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 4U\�11 j <br /> ❑ Public ❑'Other ❑ Delta Depth of Grout Seal Type of Grout �y <br /> ❑ Irrigation <br /> ---Approx. Depth ❑ Eastern Surface SealInstalledby <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material.{top 501 r <br /> Depth Filler Material (Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is (fin <br /> vailable within 200 feet.) �) <br /> Installation will serve: Residence_ Commercial— Other i <br /> i <br /> Number of living units: Number of bedrooms a <br /> i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK © Type/Mfg' -Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance td nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No'."& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:. Well Foundation Property Line ' <br /> SEEPAGE PITS ❑" Depth i -S ize Number <br /> t. SUMPS ❑ . Distance to nearest: . Well Foundation Property Line ". <br /> DISPOSAL PONDS ❑ I. I <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 1 <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." t , <br /> The applicant must pail for all req .red i t pections. Complete drawing on reverse side. <br /> ned X <br /> Title: �q".IL wu Date: ' 3 'P �. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date —i 3 Area I <br /> Pit or Grout Inspection by Date incl Inspection by Date <br /> tt <br /> Additional Comman s: <br /> ❑ Stk 466-6`781 fl Lodi 369-3621 ❑ Manteca 823-7100/7--0 Tracy 8355-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Service 601 E. Hazelton Ave., P.O. Box 2009, %k., CAFEE ( <br /> 40 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK, RECEIVED BY' DATE PERMIT NO. <br /> + EH 13-24{REV.1/8 51 <br /> EH 14-26 <br />