Laserfiche WebLink
` { APPLICATION FOR PERMIT <br /> i <br /> SAN JOQO.UIN LOCAL HEALTH DISTRICT � <br /> 1601 E. HAZEL T ON AVE.;.STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .: (Complete in Triplicate) <br /> f <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.%, t <br /> Job Address ,L city Lot Size <br /> -. <br /> Owner's Name <br /> �}��ierr Address �/~3�`O/P11on -� <br /> � Phone <br /> Contractor <br /> S P.t> dress � "License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION.1�•P,� TSYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k" INTENDED USE TYPE OF_WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> k r 12 Delta <br /> Depth of Grout Seat Type of Grout <br /> ❑ Public ❑ Other <br /> ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump - H•P• j State Work Done <br /> { Sealing Material (top 50'! 7ste <br /> Well Destruction ❑ Well Diameter 9Depth - FillerMaterial (Below 50'!TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No shin 7pubfirer iseet- <br /> Installation will serve: Residence Commercial— Other1Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: it <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposa <br /> PKG. TREATMENT PLT. ❑ , <br /> Distance to nearest: Well Foundation Property Line <br /> l • <br /> ( Total length/size <br /> LEACHING LINE ❑ No. & Length of lines I <br /> FILTER BED ❑ Distance to nearest: Well Foundation. - Property Line +� <br /> SEEPAGE PITS ❑ Depth Size Number <br /> � SUMPS ❑ Distance to nearest: Wel! Foundation � <br /> 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 D'tWici.' ; E 1 <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 workhi�n'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 /> r ..k- <br /> The applica:nt�nmf_rI req ' d' ctions. Complete drawing'on r" e !de.; <br /> Date: <br /> i Title: ' <br /> Signed <br /> DEPARTME_NT'USE ONLY <br /> Date Area <br /> /4pplication Ac4�pted by <br /> W"t- _? Data <br /> `F Pit or Grout In <br /> by Date <br /> j I dditionai Comments_: <br /> b, '°` ❑ S466 6781 ❑ Lodi 369 3621 El Manteca 823-7104 El Tracy <br /> tk <br /> 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-241REV.t/e5) <br /> EH 1426 a '� <br />