Laserfiche WebLink
APPLICATION FOR PERMIT �`Q <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT D Sala <br /> � <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 JUL <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED { <br /> (Complete in Triplicate) AMENTAL. HEALTH <br /> Application <br /> is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th ��••���„`{#``jj�' <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weli/pump and the Rul u 1 ns o t e San Joaquin <br /> Local Health District. <br /> PM <br /> Job Address <br /> f(/ ! F City tot Size <br /> Al <br /> re ss hone <br /> Owner's Name /� - �fIF r <br /> Contractor <br /> �,[ r” Address `e � License N��P �� Phon, p <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION,❑ r SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �` SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom 11 Manteca Dia. of Well Excavation, <br /> Dia. of Well Casing <br /> DYbomesticlPrivate ❑ Gravel Pack U1 Tracy Type of Casing <br /> { Specifications <br /> i"1 Public <br /> Cl Other F. Delta Depth of Grout Seal ! Type of Grout <br /> I I Irrigation' --Approx. Depth l I Eastern Surface Seal Installed by - <br /> e 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 1 REPAIRlADDITION 1.1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> A. <br /> a Installation will serve: Residence_ Commercial� Other� �*' , <br /> Number of living units: Number of bedrooms <br /> j - $ Water table depth <br /> Character of soil to a depth of 3 feet:' <br />[ SEPTIC TANK � ❑ Type/Mfg Capacity- No. Compartments <br /> • .— - I Method of Disposal <br /> PKG. TREATMENT PLT. ❑ � <br /> I , ." +�+ Foundation Property Line <br /> L, A c.....�� Distance to nearest.. <br /> F LEACHING-LINE C1 No. & Length of es 'Ntottal length/size <br /> FILTER BED '�" ❑ Distance to rest: Well Foundatia a'° t Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: " Well Foundation "` i Property Line <br /> DISPOSAL PONDS ❑' r <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 /> i 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 certify that in the perfor�ante of the work for which this permit is issued, shall employ persons subject to workman's compensa- <br /> lion taws of California." 4 <br /> The applicant ust call for all <br /> required inspections. Complete�draawing o everse side. [; <br /> / f _ L�LFitle: Date: <br /> Signed X —"�+ �. <br /> F91R DDIEPARTMENT USE ONLY <br /> Application Accepted by ,. - Date Area <br /> k Pit or Grout Inspection by Date Final Inspection by Date <br /> /� li <br /> Additional Comments: <br /> + ❑ Slk 466-6781 ❑ Lodi 369-3621 e ❑ Manteca 823-7104 ❑ Tracy 635 6385 <br /> I rmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health PeCK <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY BATE PERMIT'NO. <br /> INFO <br /> + EH 13-241REV.rIK5) <br /> EH 1448 <br />