Laserfiche WebLink
i <br /> APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT o3cv— <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 NO <br /> PERMIT EXPIRES 1 YEAR FROM DATEraISSUED �?ER D L� G'r�+� <br /> uU13it� !], r�.Lt:l:{Complete in. Triplicate). ik: <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:1,549 for sewage or No. 1862 for well/pump,and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 1 Job Address City Lot Size x PM <br />! <br /> ,Owner's'Na' e AddrerC] <br /> ss QS ��^ /Phone <br /> Contractor Address License No. Phone ~ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR ECIFICATIONS <br /> f <br /> t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca la. of Well Excavation , <br /> Dia. of Well Casingly <br /> ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing <br /> Specifications _ 1 <br /> ❑ Public CI Other F7 Delta Depth of Grout Sea! Type of G �v <br /> rout <br /> I <br /> Irrigation pprox. Depth ❑_*Eastern- Surface Seal Installed by .---- <br /> f Repair Work Do Type of Pump <br /> H.P. State Work Done <br /> Well Destruction ❑ Well Diameter { <br /> Seating Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L7 t REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> j available within 200 feet.I <br /> Installation will serve: Residence i Commercial— Other <br /> Number of living units: Number of bedrooms EF <br /> Character of soil to a depth of 3 feet: #. "/ ,., ,., I <br /> Water table depth `-'-- -- <br /> SEPTIC TANK ❑ Type/Mfg ' F <br /> Capacity � # No. Compartments <br /> PKG. TREATMENT PLT. ❑ �'- <br /> 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines I Total length/size <br /> FILTER BED ❑ Distance to nearest: Wella- -••�-----Foundation--- Property Line7" <br /> i <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> SUMPS ❑ Distance to nearest: .t Well- Foundation <br /> Property Line <br /> DISPOSAL PONDS ❑ <br /> I <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 District. <br /> Home owner or licensed agent's signature certifies the following: 1 certify that in the performance of the work for which this permit is issued, I shall not I <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 /> � <br /> Thp applicant must c all required ins ons. Complete drawing on reverse side. <br /> 9 <br /> i ned X Title: Date: <br /> i <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by T '`� <br /> A - Date _Q ` Area <br /> Pit or Grout Inspection b - - Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Ll Lodi ,369-3621 ❑ KWteGa .823-7104 a-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 /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ZINO. <br /> EHi3-24{REV.tixs)EH 14.28 �- �'"1] . <br />