Laserfiche WebLink
>1t <br /> • APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 16011E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR"FROM DATE ISSUED t <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City TeC� Lot Size —PM <br /> Owner's Name % �'1ti-��'\ Address S �� 't/ r It��L.r�pJL �_ Phone <br /> Contract9q J< Address 1 r.�• l�C � License No..3a�arr�� Phone ��` rQs­ <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 FLD. PROP. LINE/ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS, <br /> INTENDED USE TYPE OF WELL PROBLEMAREAf CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom •- —El-Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> ❑ Domestic/Private '—❑'Gravel-Pack' ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ OtherO-Delta . .�+ Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ------Approx. Depth ❑ Eastern ; Surface Seal Installed <br /> Repair Work Done Or Type'of.Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth r iller Material {Below 501 t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI /ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is 1 <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial'_ Other j <br /> Number of living units: Number of b rooms <br /> i <br /> Character of soil to.a depth of 3-feet: Water table depth 6 <br /> SEPTIC TANK ElType/Mfg i' Capacity ` J No. Compartments i <br /> PKG. TREATMENT PLT. ❑ 'I"% .r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of')ines 'S-6 Q. —10 _ Total length/size >{ <br /> FILTER BED ❑ Distance to nearest: 1 Well_._., Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Site. ' Number <br /> SUMPS ❑ Distance to nearest: Well'- Foundation Property Line <br /> „ . <br /> DISPOSAL PONDS ❑ <br /> r <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. r <br /> Home owner or licensed agent's signature certifies the following: "Icertify thavin 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." I <br /> The applicant st call for all r quit inspections. Complete,drawing on reverse e. <br /> Signed '— —Title:— - — — — — Date: <br /> T FORD PARTMENT USE ONLY <br /> Application Accepted by t —Date `'�"— 7 `�1h.,� Area <br /> P--it-or-Grout Inspection-by--- - -- - Date - Final Inspection by � -f///l ate <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 /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 MEV.1/65) <br /> EH 1426 <br />