Laserfiche WebLink
f <br /> ' APPLICATION FOR PERMIT <br /> w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> i 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 /> I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local health District. t <br /> 1lT� Jl� �07 <br /> Job Address �� J City � Lot Size PM <br /> Owner's Name Address Phone <br /> 9-t <br /> Contractor i I Address License No. Phone <br /> I TYPE OF WELL/PUMP. .w NEW WELL ❑ WELL REPLACEMENT ❑ 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 PITSISUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA ' -CONSTRUCTION SPECIFICATIONS (� <br /> ° ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type cf_Casing Specifications <br /> M Public C1 Other ❑ Delta Depth of Grout-Seal Type of Grout r <br /> I I Irrigation Approx. Depth �I I Eastern SurfaceSealInstalled by <br /> Repair Work Done ❑- Type of Pump H.P. State Work Done_ I <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 <br /> Depth r Filler Material l8elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.') REPAIR/ADDITION 1 .1 ,_DESTflUCTION`bQ INo septic system permitted if public sewer is <br /> t 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 /> 6' SEPTIC TANK ❑ -Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> k Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to clearest: Well Foundation Property Line <br /> _ _- .. <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS L1 Distance to nearest: Well Foundation 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 District. . . I <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 must c II for all re ired pection�. Co late drawing on reverse side. <br /> r Sig d X Title: I Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by_ Date _ � Area" <br /> Pit or Grout Inspection by ( Data Final Inspection by Date IS <br /> f Additional Comments: �y <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> f . <br /> FEE AMOUNT DU AMOUNT-REMITTED C SH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a EH 13-24(REV. H 5) <br /> EH 14-28 <br />