Laserfiche WebLink
F 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 San Joaquin <br /> Local Health District, g <br /> s 1 <br /> Job Address <br /> City r Lot Size �� PM <br /> R COwner's Name �(��Q }- Address Phone �- <br /> �. - <br /> Contractor P ddress Vv p /' k <br /> t_icerise No.3, � Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, <br /> AE�1Q PROP. LINE <br /> —�.... r-..« 4 FOUNDATION AGRICULTURE-WELL -- - ------OTHER WELL -i ; - PITS/SUMPS--_= <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT NS T <br /> ❑ Industrial �/ <br /> El Bottom ❑ Manteca Dia. of Well Excavatiopr v Dia. of Well Casing <br /> Domestic/Private ^Gravel Pack Tracy Type of Casing f� <br /> f`l Public .� Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation Type of Grout <br /> g" -Approxi-Depth I.I Eastern Surface Sea! Installed by h <br /> Repair Work Done L3 Type of Pump H.P. State Work Done i <br /> Well Destruction ❑ Well Diameter " <br /> Seating Material (top 50') , <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.) REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial— Other available within 200 feet.) <br /> Number of living units: Num9er of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> r <br /> SEPTIC TANK ❑ Type/Mfg. Capacity <br /> PKG. TREATMENT PLT. 1-1 <br /> e <br /> ethod of pispo <br /> Distance to nearest: Weil Foundation operty Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length size <br /> FILTER BED ❑ Distance t nearest: Well Foundation <br /> Property Line <br /> UNIV1MNIVIENTAL HEALTH! <br /> SEEPAGE PITS 11> Depth I Size <br /> ,.,. SUMPS Foundation -JProperty <br /> .. <br /> p y <br /> ❑. .Distance to nearest: Well aon Pra ert Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that( 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. <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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." 1 1. <br /> The applicant st c for all re inspections. Complete drawing on rev se side. <br /> Signed Title: �( <br /> ` Date: <br /> FD DEPARTMENT USE ONLY �7 <br /> Application Accepted by —Date o 0 0 <br /> Area <br /> Pit or Grout Inspection by Date _ Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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. Box 2009, Stk., CA 95201 <br /> 4.i <br /> FEE <br />.. INFO AMOUNT DUE - AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'No. <br /> +.EH 13-24{AIV.r/H 5) <br /> EH 14-28 (2 <br /> I <br />