Laserfiche WebLink
4 <br /> 3 - <br /> ��/// � APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 A <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 <br /> 4 made in compliance with San Joaquin County Ordinance No.549 for sewage or N_o. 1862 for well/pump and the Rules and Regulations of the San Jo <br /> i Local Health District. is <br />! Joaquin <br /> Job Address <br /> # City �'/� Lot Size �C " <br /> Owner's Name � �_r "} PM <br /> — i�]e 4 L]�_1� ` Address <br /> hp/ Phone 7 �— <br /> Contractor <br /> TYPE OF WELL/PUMP: Address <br /> NEW WELL ❑ License No. _%Phone <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUCTION C <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> --� SEWER LINES DISPOSAL FLD. ' <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> r INTENDED USE TYPE OF WELL OTHER WELLS PITS/SUMPS i <br /> El Industrial PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Open Bottom ❑ Man~— teca Dia. of Well Excavation <br /> ❑ T <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing �J <br /> ('7 Public racy Type of Casing v <br /> Other f7 Delta Specifications <br /> I ! Irrigation Depth of Grout Seal <br /> y <br /> Repair Work Done ❑ Surface Seal Installed by — <br /> Type of Pump H P <br /> Well Destruction ❑ Well Diameter State Work Done - f� <br /> Sealing Material (top 5(y) Utt1 <br /> Depth Filler Material (Below 50') (T <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION A {No septic system permitted if public sewer is r\ <br /> Installation will serve: Residence XCommercial_ Other available within 200 feet.) i <br /> �� <br /> Number of living units: —L— Number of bedrooms <br /> Character Of soil to a depth of 3 feet: <br /> SEPTIC TANK )0' Type/Mfg © Water table depth <br /> PKG. TREATMENT PLT. El # Capacity No. Compartments <br /> Distance to nearest: Well Method of Disposal d <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS i I ,Depth <br /> Size Number <br /> SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS q Foundation Property Line <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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certifythat in the <br /> performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of California." U <br /> The applicant must call for all required ins ctions. Complete drawing on reverse side. <br /> Signed i <br /> Title- <br /> Date: <br /> F <br /> �RT�M�E�NTUSE�ONLY w <br /> Application Accepted by / <br /> Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Dat eI <br /> Additional Comments: � <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 95201 <br /> i <br /> B <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CASH RECEIVED BY DATE <br /> PERMIT'NO. <br />+ EH 13-24IREV.1ix51 � � r3 !o <br /> EH 14-29 <br />