Laserfiche WebLink
1 <br /> y, APPLICATION FOR PERMIT f <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT - <br /> r 1601 E. HAZELTON 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 /> ,, / ZI I <br /> Job Address 7` '�1 /!/• Gt'V �►'¢✓' City S✓— �/ Lot Size PM <br /> Owner's Name Address sem' /�Gc��""'— Phone ! 1 <br /> Contractor _Address License No. Phone <br /> TYPE OF WELL/"PUMP: I`. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. PROP. LINE <br /> .c , <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 E��x,cca�ava6 n Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casi�g -, °� Specifications <br /> i f <br /> n Public ❑ Other FI"Delta Depth of Grout,Seal Type of Grout <br /> I Irrigation f pprox. Depth { I Eastern Surface Seal Installed by---,,:?* _ <br /> Repair Work Done ❑ Type'pof Pump H;P. State Work Dane i 'n <br /> Well Destruction O Well Diameter A Sealing Material atop 50'1.- v r <br /> DeptFl Fiile'r Material (Be1 1 1 <br /> TYPE OF SEPTIC WORK: NEW <br /> INSTALLATION I I REPAIR/ADDITION I DESTRUCTION" septic system permitted if public sewer is I <br /> within 200 feet.) <br /> Installation will serve: Residence— Commercial _ Other C <br />— 3�Number of living units: I Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 1 ❑ Type/Mfg Capacity " No. Compartments <br /> PKG. TREATMENT PLT. ❑ I� a Method of Disposal <br /> f ' <br /> Distance to nearest: Wel€ Foundation Property Line <br /> P IM <br /> LEACHING LINE ❑ No. & Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I� <br /> SEEPAGE PITS I 1 D f pth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONIJS ❑ <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. <br /> Home owner or licensed agent'sisignature 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." <br /> The applicant must call for all equir d inspections. Complete drawing on reverse side. <br /> Signed Title: Date. �— <br /> FLORA,�RTMENT USE ONLY <br /> C <br /> Application Accepted by Data 'Area. <br /> Pit or Grout Inspection by �Date Final Inspection by__�--_`J o,-C .t�C.C— Date <br /> Additional Comments: �� ! 11 <br /> ❑ Stk 456-6781 ❑ Lodi-11: -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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY"` DATE PERMIT NO. I <br /> INFO SH <br /> +.EH t3-21 IREV.I/n51 3 '� <br /> EH 14-26 <br />