Laserfiche WebLink
I, 7 <br /> 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 .il, <br /> I y T 8(Cortmplete 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 /> "` <br /> Job AddressGty �Y/ Lot Size PIM <br /> Owner's Name ddress �� Phone <br /> gfc•e �- <br /> Contractor Addres r Q License No. To Phon �"�`� �' <br /> TYPE OF WELL/PUMP: NEIN WELL ❑,, WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ' PUMP INSTALLATION,[],_:__;.�,o--SYSTEM REPAIR'1]� OTHER U] 4� <br /> DISTANCE TO NEAREST: SEPTIC TANKT._ „R SEWEA..hINES#.. c <br /> _'i -DISPOSAL FLD. PROP. LINE <br /> ! FOUNDATION . AGRICULTURE 1NELL=' OTHER WELL PITS/SUMPS _ <br /> s ___ ____ <br /> I INTENDED USE TYPE OF WELL '�PROB EEM AREACONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Cl Open Bottom Q AA_anteca ��P•Dia?of:Well,Excavatiori%"y �+ _ Dia. of Well Casing <br /> ❑ Domestic/Private <br /> El Gravel Pack ❑.Trac`y -Type-C%Casinw: . 1 S <br /> _ pecifications <br /> ❑ Public El Other k O Delta Depth of Grout Seal p° s Type of Grout <br /> El Irrigation <br /> --Approx. Depth ❑'Eastern � s Surface Seal Installed by <br /> r <br /> i Repair Work Done Cl Type of Pump H:P. State,Work:Done <br /> Well Destruction ❑ Well Diameter SeaJingrM to ePial (top 50'I- <br /> { <br /> Depth Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR'/ADDITION Q1 DESTRUCTION ❑*lNo septic system permitted if public sewer-is <br /> + � available within 200 feet.! <br /> `Installation will serve: Residence_ Commercial_ Other <br /> � lNumber of living units: Number of bedrooms - <br /> jnr V <br /> E Character of soil to a depth of 3 feet: ' - Water table depth i <br /> i SEPTIC TANK ❑ Type/Mfg Capacity Nol Compartments r <br /> PKG.TREATMENT PLT.❑ ""'r <br /> M4od of Disposal � t <br /> Distance to nearest: Well Foundation Property.,Line. I <br /> LEACHING LINE �2r_No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ell 4(l-S Foundation Q Property Line e <br /> c .a <br /> SEEPAGE PITS Depth ' Size rt Number . <br /> SUMPS Distance to nearest: Well its- Foundation .!W Property Liner <br /> DISPOSAL PONDS ❑ <br /> 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. ` �,...T.�-� -t a <br /> Home owner or licensed agent's si nature certifies the f, lowin ormance �"� w <br /> g 9 g: "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 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 o lifornia." ,1 <br /> L The appli nt m call for a equ d inspections. complete drawing on reverse std <br /> ! r Signed X Title: Date: <br /> Y FOR DEPARTMENT USE ONLY <br /> Application Accepted by ...4. Date Area• '` F <br /> � <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> A. <br /> Additional Comments: <br /> ❑ Stk 466-6781 '�KLodil 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ` <br /> Applicant- Return a copy to: Enirironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> a INFO AMOUNT DUE AMOUNT REMITTED C ` RECEIVED'BY DATE PER <br /> + EH 13-24(REV.I/a 5) ' .- ////'' <br /> EH 14-28 • C]Q � ..�7 � R!•�.�j� <br />