Laserfiche WebLink
y <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE T ON 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. / I <br />t 4 <br />W <�tee City Lot Size PM <br />Job Address <br />t {--1 m t t <br />RECEIVED BY <br />DATE <br />Owner's Name — <br />Address �� ' " –� P e <br />����+�— A 614 <br />Contractorddress <br />License No. Phone <br />TYPE OF WELL/PUMP: <br />NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION _ <br />PUMP INSTALLATION 11 SYSTEM REPAIR 11 OTHER �sat,� C,Or. ►{ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES VNA (DISPOSAL FLO. _ PROP. LINE <br />FOUNDATION ____ AGRICULTURE WL OTHER WELL PITS/SUMPS <br />EL <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing <br />0 Domestic/ Private <br />❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />F1 Public <br />1:1 Other ❑ Delta Depth of Grout Seal Type of Grout <br />I I Irrigation <br />__. Approx. Depth I I Eastern Surface Seal Installed by _ <br />Repair Work Done ❑ <br />Type of Pump H. P. State Work Done <br />Well Destruction ❑ <br />Well Diameter Sealing Material Itop 501j <br />Depth Filler Material (Below 501 —_ <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: <br />Residence _ Comme Other <br />Number of living units: <br />Number of be r om <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />❑tl.->Method of Disposal <br />Distance to nearest: Well—AfAirndation Property Line <br />LEACHING LINE <br />L1 No. & Length of lines Total length/size <br />FILTER BED <br />❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS <br />I I Depth Size _ Number <br />SUMPS <br />1_1 Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS <br />❑ <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'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 call f r all a fired ins coons. Complete drawing on/reverse side. V <br />Signed X Title: Date: `' <br />FOR DEPARTMENT USE ONLY yam,/� <br />Application Accepted by �/%� _-_ _ Date u <br />C. <br />Area <br />Pit or Grout Inspection by Date Final Inspection by �/ ' / Dat �G <br />Additional Comments: <br />❑ Stk 466-6781 O Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 <br />Applicant - Return all copies to- Environmental Health P rmit/S rvi es 1601 E. Hazel on Ave., .0. BoxQ09, Stly., CA 95201 71 <br />14 <br />EH 13.24 IREV. 1/ n 5) <br />EH 14-26 <br />IEEE NFO <br />DUE <br />AMOUNT REMITTED <br />CK'AMOUNT <br />CASH <br />RECEIVED BY <br />DATE <br />PERMIT <br />ZNJO. <br />L.i <br />