Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pl (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. 544 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> I� - City PM <br /> Job Address <br /> Lot Size <br /> I I, Address dres. Phone <br /> �� 4 � ` - <br /> Owner's Name <br /> 31 W %',�'�( Phone/ <br /> Contractor Address �J License N0.f <br /> TYPE OF WELLIPUMP: NEW'WELI""❑"'--'WELL`REPL'ACEII+TENT-❑—DESTRUCTION-O---�-•^^^ - �- <br /> „r J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWS. LI S DISPOSAL FLO. PROP. LINE 4 <br /> I FOUNDATION AGRIC RE WELL OTHER WELL—. PITS/SUM <br /> PS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of WeA Casing <br /> ❑ Domestic/Private ❑ Glravel Pack ❑ Tracy� � Type of Casing Specifications <br /> ...T .�-. <br /> C i Public a ❑ Other ❑ Delta Depth of Grout Seal ` Type of Grout <br /> ` <br /> I I Ifrigation , Approx. Depth ) i Eastern Surface Seal Installed by V <br /> Repair Work Done ❑ Typ F of Pump t H:P. State Work Done <br /> Well Destruction ❑ ( Well Diameter _.— Sealing Material )top 501 <br /> Depth ' Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION`I 1 REPAIR/ADDITION 1 1 DESTRU ION INo septic system permitted if public sewer is <br />' 1 �� f /� •�., available Wthin 200 feet.) <br /> It Installation will serve: Reside�ppence_ Commercial— Other <br /> Number of living units:)—_•i_ Number of bedlooms + <br /> Character of soil to a depth- f 3 feet: <br /> -' ' Water table depth 1 <br /> SEPTIC TANK E3Type/Mfg .�— Capacity' No. Compartments <br /> PKG. TREATMENT PLT.❑ j x Method of Disposal ' <br /> ` Distance to nearest: Well Foundation Property Line <br /> t iM i <br /> LEACHING LINE ❑ ;No. & Length of lines Total length/size f <br /> FILTER BED El :Distance to nearest.: Well Foundation Property Line I <br /> SEEPAGE PITS [;I ;Depth Size Number ; <br /> SUMPS 0 'Distance to nearest:'_­Well —Fou ndafion�= Pr Y Line <br /> DISPOSAL PONDS ❑-��'�"""'-�� � �.�T�� ���� <br /> :f. <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 Di§trict. r r <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." ­ w t i,;_-� .a <br /> The applicant ust call fforequire inspections. Complete drawing on reverse side. f <br /> �•-._� Data: <br /> Signed X Title: <br /> FOR DEPARTMENT USE ONLY {` <br /> DateArea <br /> Application Accepted by y` <br /> Pit or Grout Inspection by �I Date Final Inspection by Date <br /> Additional Comments: <br /> y ❑ Stk 466-6781 ❑ L8di 369-3621 0 Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant Return all <br /> copies' Environmental Health Permit/Services 1601 E. Hazelton Ave P.O. Box 2009, Stk., CA 95201 �. <br /> FEE AMOUNT DUE AMOUNT REMITTEDECK RECEIVED BY' DATE PERMITNO. <br /> INFOSH <br /> +.EH 1321(REV.t/'R 5) llE <br /> 'IIS �919Y <br /> EH 11-26 <br />