Laserfiche WebLink
-j1O 0 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 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 /> '4( s <br /> Job Address City Lot Size PM <br /> Owner's Name � � Oen �gess Phone � v4 <br /> 44 <br /> Contractor's Name _.,_ nse No. Phone <br /> IN 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. 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 <br /> ❑ Domestic/Private' <br /> ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other, f ❑ Delta Depth of Grout Seal Type of Grout v <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 501 <br /> Depth', Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.), 0 <br /> Installation will serve: Residence /1"Commercia! Wnthar <br /> Number of living units:_I— Number of b oms <br /> Character of soil to a depth of 3 feet: Water table depth 7— <br /> SEPTIC TANK Type/Mfg �y, Capacity _ No. Compartments <br /> PKG. TREATMENT PLT_. ❑ Method of Dis o�a1 f' <br /> Distance to nearest: Well Foundation__1Property Line <br /> LEACHING LINE No. & Length of lines Total length/size _ <br /> FILTER BED ❑ Distance to nearest: ell Foundation C�• Property Line <br /> �4 <br /> SEEPAGE PITS r4x Dept}1 Size r��t NLImber _ <br /> CD 'Distance to nearest: Well fie Foundation Property Line— <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 /> 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." <br /> The applicant must.-,eA must.-,eforx1l req �mspections. Complete drawing on rse side. <br /> ff <br /> Signed Title: `� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date Area / <br /> Pit or Grout Inspection by r Date Final Inspection byDate <br /> Additional Comments: S, d� Z/11 <br /> fV <br /> ❑ Stk 466.6781 ❑ Lodi 3693621 ❑ Vanieca 823-7104 ❑ acy, 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., 95201 <br /> FEE AIUOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. <br /> INFO <br /> + EH 13-24{REV.10/83? ► <br /> EH 1428 CD, oc, \ _I O <br />