Laserfiche WebLink
v h <br /> APPLICATION FOR PERMIT S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA IVOkm <br /> Telephone (209) 466-6781 D�,._� Al-k <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDNo Y"" <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 City Lot Size .rte. PM <br /> Owner's NameAddress �� Phone <br /> t 50 PI <br /> 1 Contractor Address � License No,yZTn27�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 WA=LL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t <br /> ❑ .Domestic/Private ❑ Gravel Pack [!;'Tracy Type of Casing Specifications <br /> M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _._..Approx. Depth ( I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. 1 State Work Done <br /> is <br /> Well Destruction D Well Diameter Sealing Material ftop 50,, <br /> Depth Filler Material (Below 50'1 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRJADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is <br /> i available within 200 feet.] <br /> Installation will serve: Residence X Commercial— Other <br /> Number of living units: -__F—. Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK NC Type/Mfg Capacity-1-2z) __— No. Compartments <br />[ PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length•of lines.. ` ? Toial length/size <br /> a 'St'. <br /> FILTER BED ❑ Dist5ance to nearest: •f,c Well Foundation Property Line <br /> SEEPAGE PITS }% i I DepthttSiz��e r Number <br /> SUMPS LI .ristance to nearest: ell Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepa'rad;this application and'that.�he 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. Ei <br /> I 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,.l 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 requi d Inspections. Co eta drawing on reverse side. <br /> Signed X 1 Title: Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date .Final Inspection by Dateo <br /> 77 <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK . RECEIVED BY DATE PERMIT-NO. <br /> INFO �] ^CASH !r �j r� ��1/ <br /> +.EH 43,24 IREV.t/H5) E.f7i'Tr]J �,,f'2„y�� d��-r-7 -L1 ( 11 ! Q � p� rp <br /> EH 14-26 <br />