Laserfiche WebLink
4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k 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 /> Applicatio42i <br /> San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in comJoaquin 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. I <br /> Job Address —f ; ,3 _5 T?4 C Cr City ZA A10441 Lot Size 116 XS.�- PM <br /> tt <br /> Owner's Name III)' s G nl Z AW96•'KFAddress L l tUi' Phone ��y <br /> Contractor Address.-l V Z�3 SY" License No. r Phone 2"l 7 <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 /> r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ OPen <br /> Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications <br /> i`1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __._,_Approx. Depth l I Eastern Surface Seal Installed by (In <br /> Repai <br /> - <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 (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.'] REPAIR/ADDITION LI DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) I <br /> Installation will serve: Residence; Commercial_ Other <br /> Number of living units: Number of bedrooms <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 to 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 /> - i <br /> SEEPAGE PITS I I Depth Size Number <br /> 1 <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 call for all required inspections. Complete drawing on reverse side. r <br /> L <br /> Signed X Title: Date: <br /> R DEPARTMENT USE ONLY <br /> z { <br /> Application Accepted by Date 3_ Area <br /> Pit or Grout Inspection by Date Final Inspec J_ b Date �a <br /> Additional Comments: <br /> ❑ Silk 466-6781 ❑ Lo 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 <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 CK RECEIVED BY DATE <br /> INF CASH PERMIT'N0. <br /> + EH13-24 MEV.i/0'5) U t;J <br /> EH t42e -- <br /> - i <br />