Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 !.L r City t Size PM <br /> Owner's Name�nle--' Phone^ <br /> 7 <br /> Contractor Address License No,IA6– h" ne <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 PROBLEM AREA CONSTRUCTION SPECIFICATION N c , <br /> ❑ Industrial ❑ O Bottom LI Manteca Dia. of Well Excavation Dia. of Well Casing V(Z u <br /> ['Domestic/Private Gravel Pack 1=1 Tracy Type of Casing Specifications �} <br /> f Public F1 0th r Cl Delta Depth of Grout Seal a Type of Grout <br /> I i Irrigation .?Pprox. Depth l I Eastern Surface Seal Installed by 4! IAlez <br /> Repair Work Done type of Pump .- H.P. State Work Hone <br /> Well Destruction [if' Well Oiamet r �r Sealing Material (top 50') <br /> Depth r AMP101116 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial__ Other <br /> }_ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 6 _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation rpProperty-Line. .� <br /> SEEPAGE PITS I ) Depth Size Number s <br /> SUMPS Ll Distance to nearest: Well 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 regulationsof th Joaquin Local Health District. <br /> Home owner or licensed agent's ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any pars in such maryfer as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the f owing: 'I card t t in the perfo nce of a ork for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws California." <br /> The a licant m st at I requir i plete awing on revef <br /> Si a <br /> Date: <br /> FOR—DEPARTMENT USE ONLY / �7 �7-t <br /> Application Accepted by Date [ I ZArea 4! ads �yQ <br /> Pit or Grout Inspection by Date i Final Inspection by Date <br /> Additional Comments: f o a 0. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7164 ❑ Tra 65-d385 <br /> Applicant- Return all copies to: Environ ental Health Permit Services 1601 Hazel on Ave, P.O. Box 2009, Stk., CA 95201 <br /> r,��� s.� � ��/� - �.d ��I� i{ — cad s G <br /> FEECK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH13-21(REV.tiKs) /// "� RE4 <br />