Laserfiche WebLink
Z <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA kJ ' <br /> Telephone 1209) 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 /> Job Address _1CJ. e7[.0 City Lot Size PM <br /> Owner's NameAdd/res�s / <br /> Contractor?�%J� j� Address 4 9 (JP6 �i�l License &� Phon 7CJ <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. P E <br /> FOUNDATION AGRICULTURE WELL OTHER WILL--- PITS/SUMPS ^y <br /> INTENDED USE TYPE OF-WELL -PROBLEM-AREA- - CONSTRUCTIOIFICATIONS , <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑.Tracy ype of Casing Specifications 4° <br /> 1-1 Public f] Other ❑ Depth of Grout Seal Type of Grout . <br /> i I Irrigation _.-Approx. D I Eastern { 'Surface Seal installed by _ <br /> Repair Work Done ❑ Type mp H.P. State Work Done <br /> Well Destruction ell Diameter Sealing Material (top 50'i <br /> Depth Filler Material (Below 50') i <br /> TYPE'OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I I DESTRUCTIO (No septic system permitted if public sewof is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial- Other j <br /> Number�of,living units: Number of bedrooms <br /> Character-6f s6il to-a depth of 3 feet: Water table depth <br /> SEPTIC TANK� ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT: ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property t Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property LinekT j <br /> t <br /> SEEPAGE PITS I I Depth Size _ Number I� <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line J <br /> DISPOSAL PONDS ❑ 1 <br /> I <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. i <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 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 /> Th2f! <br /> r all required ins ctions. Complete drawing on rev se side. r , <br /> Sig ~Title: Date: <br /> " 7FOR'DEPARTMENT USE ONLY / <br /> ApDate ' Area <br /> Pit or Grout Inspection by Date Final Inspectiomby Date <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 PERMITNO. <br /> EH 3-24+ EH 14-26(REV,tins) c1V i 10-2d—&Z —10 <br />