Laserfiche WebLink
k r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 San Joaquin <br /> Local Health District. QQ r <br /> FJobAddress �, (f 3 -K Cit /IfY � Lot Size pM <br /> r I s i C•. '�[me ���1 Address Phone <br /> Address License No. Phone_ <br /> TYPE OF WELL/PUMP: it NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ THER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1111111SPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS _ <br /> :i <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavation Dia. of Weil Casing <br /> 0 Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> Fl Public' n Ot,�her ❑ Delta Depth of Grout Seal Type of Grout <br /> I } Irrigation e <br /> proit: Depth--'.I ].E_asiern�_S_urfece-Seah_lrxstalled"by <br /> Repair Work Done ❑ ype of Pump- H.P. , State Work Done <br /> Well Destruction We Qiameter" k-\'f 4 ) ea1• ` <br /> <. Sling Material-(top 50') <br /> Dept "" _, .tiler.Material"(Below 50')" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I IrREPAIR•lADDITION I")^ DESTRUCTIV (No septic system permitted if public sewer is <br /> � 1 available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: A Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK _ <br /> C7, hype/Mfg # Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑' I` i r_` Method of Disposal } <br /> Distance to nearest: Well IN Foundation Property.Line i <br /> �I 1 <br /> LEACHING LINE ❑ No.'& Length of lines k�•. Total length/size a� <br /> FILTER BED ❑ Distance to nearest: WeII� %.�---•Foundation Property Line ry' <br /> �I t _ t !" l� <br /> SEEPAGE PITS I I Depth Size r Number <br /> SUMPS 0 Distance to nearest: WellFoundation - Property Line <br /> DISPOSAL PONDS ❑ I� <br /> 1 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 Sari Joaquin Local Health D23trict. <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 manrier 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." !N. <br /> 'he applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Xvs_" I'i�t�{ Title: J �b �r� 'Dar <br /> „„ ���_. Data: _ 6 <br /> II. FOR DEPARTMENT USE ONLY <br /> d° <br /> Application Accepted by �_. DateC) <br /> Area <br /> Pit or Grout Inspecti �M to Final Inspection by Date' <br /> Additional Comments: ,!r-e- 44, <br /> ❑ Stk 466-6781 L7 Lodi°jj 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 /> gl <br /> jl. <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK <br /> INFO CASH RECEIVED BY DATE PERMWN0, <br /> . EH13-24 IREV. <br /> EH 1428 <br />