Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA { <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> • <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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. y/ <br /> Job Address <br /> City Lot Size fJGe? PM <br /> Owner's Name I Address ti ' s Phone <br /> Contractor Address �� License Nov2 Phone <br /> TYPE.OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> . G <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 /> 1-1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. . State Work Done _ J <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth --t Filler Material (Below 501 — <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION 11 REPAIRIADDITION [ I DESTRUCTION (No septic sys(erri permitted if public sewer is 1 <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial--Other <br />.r Number of living units: Number of bedrooms <br /> r <br /> Character o1 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ,Capacity . No. Compartments <br /> PKG. TREATMENT PLT. ❑ `, Method of Disposal <br /> Distance to nearest: Well. Foundation Property Line <br /> LEACHING LINE ❑ No. &iength of lines ""'" Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r. p i ^ <br /> SEEPAGE PITS I I Depth Size Number" <br /> SUMPS 'a D Distance to nearest: Well Foundation . Property Line <br /> DISPOSAL PONDS ❑ F <br /> ii <br /> I hereby certify that I have prepared this application and that the work will be done tri accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di1trict.- —"- <br /> .. _-a F . <br /> Home owner or.licensed agent's signature.certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall not <br /> employ any person in such manner as'to,becbme subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in th'e.performan6.,'of the work for which this permit is issued, !'shall employ persons subject to workman's compensa- <br /> tion laws of California." - <br /> 4 The applicant must call for all r fired ' spections. Complete drawing on reverse side! <br /> i t a- rte. <br /> Signed X 4 Title: fps. l.. - Date: �+ <br /> QR DE TME USE ONLY- <br /> Application Accepted by Date Area <br /> i ;,-� `� <br /> l Pit or Grout Inspection by Date J ' _ Final Inspection by ` Date/ <br /> Additional Comments: <br /> C1 Stk 466 -6781 ►. ❑ Lodi 369-3621, :E '❑ Manteca 823-7104 ❑ Tracy 835-6385 f <br /> Applicant-A Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> F <br /> FEE AMOUNT DUE AMOUNT REMITTED CK AECEIVED'BY, . DAT_E _ PERMIT'NO. <br /> cINFO - _ _—. _ ,CASH __ ...h - - - "-- <br /> + EH 1324 fREV.F i e 5r - <br /> EH 13,24 3� ��� �a f.7 S�— <br />