Laserfiche WebLink
i <br /> I <br /> i <br /> s 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 <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 SanJoaquin <br /> Local Health District. <br /> Job Addressr „ City f * 5 Lot Size PM <br /> Owner's Name _ Address Phone <br /> Contractor/ I Addres,' A icense N6 ` Phone`'moil r w <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 WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1A Public ❑ Other 1� f7 Delta, Depth of Grout Seal, Type of Grout _. <br /> I Irrigation _.-Approx. Depth I I Eastern Sur�ce�Seal Installed by _ <br /> Repair Work Done ) Type of Pump .ea” ---, H.P. __/ _5 Mate Work Done <br /> Well Destruction ❑ Well Diameter "'Sealing Material (top 50') r <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 11: DESTRUCTION I I lNo septic system permitted if puhlic sewer is <br /> available within 200 feet.i <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Vv <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. ❑ *, y + y Method of Disposal <br /> Distance to nearest: Well Foundation Property Line . <br /> LEACHING LINE ❑ No. & Length of lines Total length/size�x <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size r Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> r <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 Di3trict. r <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 CcV for alt required inspections. Complete drawing on re arse side. <br /> Signed X_-- �� Title: — r' .� Date: <br /> FOR,WEPARTMENT USE ONLY <br /> Application Accepted by Date Area ` <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> ❑ Silk 466-6701 ❑ 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. Bax 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH124fREV.1/K51 <br /> EH 1.28 3 Jr C-CL /_w <br /> r <br />