Laserfiche WebLink
> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> a <br /> Telephone (269) 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. <br /> � lb-eAJob Address .. City Lot Size Q-4 ! PM <br /> Owner's Name h- -: Address . IAAr � Phone ` <br /> Contractor's Name '� t` License No. A 5I 3 Phone " f <br /> TYPE OF WELLQPUMP) NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> .� PUMP INSTALLATION ON SYSTEM REPAIR ❑ OTHER ❑ <br /> l <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 SPECIFICATIONS <br /> 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ubiic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. / °� State Work Done <br /> I Well Destruction © Well Diameter Seating Material (top 50') <br /> 4 <br /> Depth Filler Material (Below 501 6 <br /> 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_ Commercial_ Other <br /> 4E • '' Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water tabledepfh�I'- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 1 Distance to nearest: Well Foundation Property Line <br /> I, LEACHING LINE ❑ No. K Length of lines Total length/size y <br /> FILTER BED ❑ Distance to nearest: Welt Foundation Property Line ff <br /> i SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation .Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> " •. Home owner or licensed agent's signature certifies the following: "t 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> R The applicantust call or all required inspections. Complete drawing on reverse side.l- <br /> JA <br /> Signed )L{ �2 _. Title: <br /> Anor _ Date: <br /> I <br /> ' FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �" `�" Area <br /> Pit or Grout Inspection by RateFinal Inspection by Date� J <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> {{ FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> EH 13241>isV.10l83T FI! -S.a3EH 1425 ee���� ((�� <br />