Laserfiche WebLink
y 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 TYEAR FROM DATE ISSUED <br /> r (Complete in Triplicate) j <br /> r <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 V ity / �� Lot Size PM <br /> Owner's Name Address f Phone <br /> Contractor '� Address � � Ifs° License No.3� 4" Phon 3 <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 FLO. PROP. LINE <br /> _ FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS_ <br /> INTENDED USE TYPEyOF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br /> ❑ In�n�al- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> 1-1 Public L1 Other Ll Delta Depth of Grout Seal Type of Grout I!_ <br /> I I Irrigation _.-_.Appror <br /> x. Dept l Eastern Surface Seal Installed by _ —0 <br /> Repair Work Done El Type of Pump H.P. / State Work Done .,_13 <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l ! REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is n <br /> i: availabl <br /> available within 200 feet.) q Y <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet". Water table depth p <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line !I <br /> LEACHING LINE ❑ No. & Leh gth of lines Total length/size E <br /> FILTER BED ❑ Distance,to nearest: Well Foundation Property LineUq it <br /> SEEPAGE PITS 1 1 Depth I Size Number SAV JOAQI LN rf3UNTY <br /> SU_MP5_ _ _ L-1 Distance to nearest: Well Foundation Prope f +C HEALTH SERVIrE q <br /> DI PL PONDS ❑ — - Cn YR I'A I TAI-HEMLTI-i I✓i1r'i iii''.. " •ice <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 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 t#e 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 call for all equired ins ctions. Complete drawing on reverse side. <br /> Signed X Title: ��� - Date: <br /> FOR PARTMENT 115E ONLY <br /> I� <br /> Application Accepted by Date - Area <br /> Pit or Grout Inspection by Date Final Inspection by Date e?//Z,?/ <br /> Additional Comments: II <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 935-6365 !! <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RfE/CyEIIVEDD BY eDATE PERMIT'NO, �! <br /> +.EH 14-26 111-24 iREV.i i n sl 1060 <br /> , ! � / r f r? <br /> EH 14 a.J II � �J <br /> Ip <br />