Laserfiche WebLink
4 -APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA S <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 /> Job Address _ ►1 a L _ city 157'0C Kr4lyLot Size _65-x l�a PM <br /> Z 5 <br /> I /1 F_ C �ddress S S Phone <br /> Owner's Name <br /> Contractor _A — - Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public L-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —_-Approx. Depth l I Eastern Surface Seal installed by - <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> t available within 200 feet.) \ <br /> Installation 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 d Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> C <br /> I LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line_ <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> ' DISPOSAL PONDS ❑ 1 <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, an <br /> �,f <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 Permititissued, 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 appiican ust call for all re ired ' pections. Cam late drawing on reverse side. rc C�7+ <br /> Signed Title: © Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by U*NDate 1 Area <br /> Da r Z- <br /> Pit or Grout Inspection cti�n �y Final Inspection by , <br /> Additional Comments: <br /> ❑1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 E5 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA M01 <br /> FEE AMOUNT DUE AMOUNT REMITTED �K RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a"EH 13-24(REV.I/x 5] S7 fGS7)�99 59 <br /> EH t4-26 <br />