Laserfiche WebLink
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 /> ICOmplete 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 CA 1 <br /> S [�•Job Address y fzPM <br /> r <br /> Owner's Name s Phone <br /> i <br /> Contractor fess 0Y. S License No. ISi t1 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C7 SYS REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE LINE DISPOSAL FLb. PROP. LINE <br /> FOUNDATION AGR IC <br /> LT E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ' Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> [-I Public f� Other ❑ Delt Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —..Approx. Depth I I E tern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Seah g Material Itop 50'1 <br /> Depth Filler Material {Belo 50') d <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION K DESTRUCTION I I (No septic system permitted if public sewer is �V <br /> available within 200 feet.) \4 <br /> Installation will serve: Residence_ Commercial_? Other <br /> Number of living units: Number of bedroomrJ <br /> Character of soil to a depth of 3 feet: r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to near st: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well A oundation � l Property tine f <br /> SEEPAGE PITS I I Depth Size ___252 Number <br /> SUMPS 0 Distance to nearest: Well I SW-6. Foundation 1� 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, an <br /> rules and regulations of the San Joaquin Local Health Di?;trict. <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 st call for as quire inspections. Complete drawing on reverse side. <br /> r <br /> Signed X Title: 4L:::6.� Date: <br /> FOR PARTMNT USE ONLY 3 <br /> Application Accepted by Date " !- V Area /� <br /> t or Grout Inspection by ate Final Inspection by /J Qate r2- � d <br /> llllll JJJJJJAdditional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-SUS <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 <br /> FEE <br /> INFO UNT DUE AMOUNT REMITTED CASH CK 11 RECEIVED BY DATE PERMIT"No. <br /> + EH 1 <br /> 3-24 IpEV.I/N 57 <br /> EH 14-26 <br />