Laserfiche WebLink
I <br /> L <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 /> 4PERMIT 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. <br /> Job Address City Lot Size <br /> Owner's Name AddressAPhone <br /> Contractor's Name r icen Phone I <br /> TYPE OF WELL/PUMP: NEW DELL 11!` *WELL REP CEMENT DESTRUCTION ❑ <br /> PUMP INSTALCATIOMMr SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM,AREA_CQNSTRU_CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑=Manteca Dia. of Well Excavation' Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy S Type of Casing- Specifications <br /> ❑ Public ❑ Other []'Delta T Depth of Grout Seal `' Type of Grout" <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done '❑ ,Type.of Pump ; H.P. State Work Done <br /> Well Destruction ❑)14 Well' iameter Baling Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> .;& I ; available within 200 feet.) <br /> Installation will serve: Residence commercial— Other <br /> 3� Number of living units:_(— Number of bedrooms I ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> ..„.iSEPTIC TANK C1Type/Mfg i� Capacity No. Compartments Q.. <br /> _ PKG:TREATMENT PLT. ❑ j 1 Method of Disposal fl+ <br /> Distance to nearest: Well ZO i� Foundation 1/�) Property Line <br /> LEACHING•LINE ❑ No. & Length of lines Total length/size— <br /> FILTER <br /> ength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r I <br /> SEEPAGE PITS ❑ Depth iii_ Size Nymber <br /> SUMPS ❑ Distance to nearest: Welt Foundation� — Property Line - <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 District. a <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 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 al or all requi ctions. CompI drawing on reve side. <br /> Signed Title: Date: <br /> F R DEPARTMENT USE ONLY , <br /> Application Accepted vy� <br /> Date r a <br /> Grout Inspection Date (m—�rs� Final Inspection by Date �L f <br /> Additional Comments: _ <br /> CI Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63% <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009, Stk., CA 95201 <br /> FEE INFO A7MOUNT DUE AMOUNT REMfTTED CK <br /> CASH RECEIVED BY DATE PERMIT`NO. <br /> + <br /> ENI <br /> IW29 3-24IAEV.10!931 <br /> EH 14- YG/..T5(. $1b-b3t� <br />