Laserfiche WebLink
` APPLICATION FOR PERMIT '3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVU- STOCKTON, GA <br /> l Telephone {2091 -678111 ; <br /> PERMIT EXPIRES 1 YEAR FR6M DATE I$SUI:D;;y <br /> (Complete in Triplicate) <br /> - � Y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the,Rules and Regulations of the San Joaquin <br /> Local Health District. p <br /> r c= <br /> 7 r0. y'i <br /> N <br /> Job Address City Q+�ry► `kt7t$►ze a PM <br /> w {� <br /> a <br /> Owner's Name G LA' ., VL +SAddress Phone <br /> Contractor's Name <br /> f"/ License No. r e phor}e;; �` ` C <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑' SYSTEM REPAIR "ATfIER ❑ 5r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F LD F PROPLIIE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSIS.WMPS Q <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � •; <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia of'INell basing \ <br /> Domestic/Private EIGravel Pqck ❑ Tracy Type of Casing 5pecifOtlpns <br /> ❑ Public O Other ❑ Delta Depth of Grout Seal Type of'GI'out, <br /> ❑ Irrigation ---4pprox. Depfil Eastern Surface Seal Installed by <br /> ' Repair Work Done Type of Pump._ H,P. 1-C-, State Work Dor+® <br /> Well Destruction © Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 „ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permittgd if public sewer is <br /> t available within 200.feet.} <br /> F Install tion~will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms ` <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg ' Capacity No, Compartments <br /> PKG. TREATMENT PLT. 11 ! f y Methgd of Disposal <br /> ° <br /> -Distance to-nearest: Well es Foundation" Propeity Line <br /> . dt. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size . <br /> FILTER BED ❑ Distance to nearest:. Well Foundation Property i lne <br /> f-� SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation fro <br /> perry;Line r <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with Sqh Joaqui'�county ordinances, state laws, and <br /> I :. <br /> rules and regulations of the San Joaquin Local Health District. " <br /> Home owner or Vicensed agent's signature certifies the following: ''I certify that in the performance of the work fpr which this permit is issued, I shall not <br /> F employ any person in such manner as to become subject to workman's compensation laws of California.".Con#iactor's hiring or s'4b contracting signature <br /> certifies the.follbWing:"I certify that_in the performance of the work for which this permit is issued, I shall emplcy persons subject to}workman's compensa <br /> tion laws of California." ' <br /> Theapp)' call for all required in ctions. omplet rawing on revs side. <br /> r <br /> Signed <br /> C Title: Date' <br /> �FR EPARTM ENT USE ONLY r•"' '�x k, . <br /> . ,v. <br /> Application Accepted by _ v Date Ar9s ,.r <br /> Pit or Grout Inspection by Date Final Inspection by r Date 7-17 <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 5tk ;CA 98201 <br /> -,> <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE .PERMIT`N0. <br /> INFO —C <br /> + EH 13-24 <br /> EH 14-28 IREV.10!831 <br />