Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (2091 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 and the Rets and Regulations of the San Joaquin <br /> Local Health District.. _ •:; fes`�q�l <br /> f tJWAI <br /> 1 PM <br /> City ; Lot Size�� <br /> Job Address <br /> Phone <br /> Owner's'Naina - .---- - <br /> �J-c�— �[ Phone �� <br /> Contractor's Name `� �0�''� License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL i PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial El Open Bottom Ll Manteca. Dia. of Well Exca�ation <br /> ` T •of Casing Specifications <br /> Ll Domestic/Private ,❑ Gravel Pack El Tracy ype g Type of Grout <br /> ❑ Public - ` ❑ Other _-. ❑ Delta i Depth of Grout Seal , <br /> ❑ Irrigation —LApprox. Depth ❑ Eastern Surface Seal Installed by I7 <br /> H P <br /> Repair Work Done Ll Type of Pump <br /> State Work Done y. <br /> Well Destruction: ❑ Well Diameter Sealing Material (top 501 <br /> Depth <br /> Filler Material (Belo 50'1 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (Nos pticvst stem in 200(remitted if public sewer is <br /> availay � * f x. <br /> R <br /> Installation will serve: Residence Commercial_ Other - <br /> Number of living units: Number of bedrooms Water table depth �Sr <br /> ' Character of soil to a depthr of 3 feet: S <br /> l ' Capacity — No. Compartmants <br /> SEPTIC TANK ®-Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. 13 ` Property Line 1 — <br /> Distance to nearest: Well, Foundation <br /> .1L— <br /> � <br /> 0 <br /> J /size <br /> LEACHING LINE E] 'No. & Length of lines Tota length <br /> + <br /> Dr Foundation Property Line <br /> — <br /> FILTER BED QY Distance to nearest: Well— - <br /> SEEPAGE PITS 4❑ Depth I Size Number <br /> SUMPS ❑ '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. ' <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,V shall employpersonssubject to workman's compensa <br /> tion laws of California." 1 <br /> The applicant must call for all required inspection§. Complete drawing on reverse e. / " _ <br /> Signed Title: Date: <br /> 9 _ <br /> n FOR DEPARTMENT USE ONLY � t <br /> Area 53 <br /> Application Accepted by ��-- Date pp <br /> i 1 Date Final Inspection by <br /> Pit or Grout Inspection by i 'ice <br /> r zl <br /> Additional Comments: ( <br /> ❑ Stk 466-6781 C1 Lodi 369-3621 ❑ anteca 823-7104 acy 835-6385 L <br /> Applicant- Return all copies to: EnvRonmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 56201 <br /> FEE CK RECEIVED BY DATE PERMIT`NO. <br /> INFO AMOUNT DUE A_MOUNT REMITTED CASH <br /> + EH 1324/REV-101831 CD <br /> EH 14.26 i <br />