Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA I <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t <br /> t (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 /> Job Address r7 ��W¢ l City ;� Lot Size PM <br /> Owner's Name <br /> (!e hJ4 S. Address r /ter ' L�- Phone <br /> -Contractor c.i C Address-/6n r License No, Phone -Ape <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-,Ll 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 SUMPS \ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU CIFICATIONS <br /> L1 Industrial EJ Open Bottom El Manteca . of Well Excavation Dia. of Well Casing \ <br /> Type L7DomesticlPrivate [} Gravel Pack 12YP of Casing Specifications <br /> n Public Cl Other I n Delta . Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation _ ox. Depth ( I Eastern Surface Seal installed by - <br /> Repair Work Done ype of Pumpr H.P. t State Work Done <br /> Well Destr C Well Diameter) Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence "Commercial_ Other <br /> Number of living units: Number of bedrooms-x 2---- <br /> 'Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ElType/Mfg Capacity No. Compartments t <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> i <br /> 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, f 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,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> T licant mu call for all required inspections. Complete drawing on reverse side( � ��� /^7 R <br /> Title: :r.11 Imo` d �*ei _ v- /tom Date: I 1 "7 <br /> Signed X I � <br /> FOR DEPARTMENT USE ONLY <br /> rArea <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection b Date Final Inspection by „ N-� Date 1w <br /> 1 J <br /> Additional Comments- X <br /> L) <br /> omment - <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Man eca 623-7104 ❑ 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 /> FEEAMOUNT DUE AMOUNT REMITTED SASH K 4 RECEIVED BY DATE PERMIT.NO. <br /> INFO O y�y "� <br /> tr r EH 13-24 EV.t/H 51 �� �Q .��� _ 17— ! <br /> EH 14-28 <br />