Laserfiche WebLink
APPLICATION FOR PER" <br /> 1 : n SAN JOAQUIN LOCAs, HEALTH WSTRICT <br /> C OP1 - A 6v 1<r 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 a <br /> cation is <br /> FFF made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the Sawn J <br /> Local Health District. Joaquin <br /> � ��� <br /> � Job Address _ �-'-" <br /> City { �� Lot Size PM <br /> Owner's Nand. Address Phone J <br /> 4 <br /> Contract orf C - c dress'`. License No Phone <br /> TYPE OF ELL/PUMP: N ELL ❑, WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> F, PUMP INSTALLATION`❑ SYSTEM REPAIR ❑ OTHER C1j DISTANCE TO'NEARE.ST:_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 SPECIFICATIONS <br /> ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing •1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material(Below 50'} <br /> �i , <br /> - j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> + Installation will serve: Residence_4""Commercial— Other <br /> ' Number of living units:L Number of bedrooms 3 <br /> f` <br /> Character of soil to a depth of 3 feet: E <br /> Water table depth lob <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I <br /> PKG. TREATMENT PLT. ❑i Method of Disposal <br /> -' Distance to.nearest: Well Foundation Property Line <br /> LEACHING LINE M`No. 9 Length of lines 1 - 40 � Total length/ ize Q 1 <br /> FILTER BED ❑ Distance to nearest: Welt Foundation Pro Line <br /> SEEPAGE PITS DepthSize Number <br /> SUMPS ❑ Distance to nearest; Well Foundation�,Prope!pjLine <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 regulations of the San Joaquin Local Health District. <br /> Horne 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 Mall 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." <br /> The applicant must call for all <br /> p regy�e specti . Complete drawing on reverse side. -��tr, 1 <br /> Signed P�1l�e Title: ._. C`7-)7 �t ' `�.'� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Area Date <br /> _ I�. <br /> CrPit <br /> Grout Inspection by \1 ... pate-- y�. Final Inspection by �- � Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 319-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> FEH 13-24(REV.f/85)EH 14-25 <br /> 1 F <br />