Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA d t'- <br /> Telephone (209) 466-6781 &cn <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 /> r <br /> Job Address City Lot Size <br /> -r <br /> Owner's Name Address —1t Phone <br /> i <br /> Contractor's Name License No. 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 <br /> FOUNDATION AGRICULTURE WELLt OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C'NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy-F Type of Casing Specifications <br /> Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair UIlork Done ❑ `Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth - Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted If public sewer is <br /> - ` available within 200 feet.) <br /> Installation wrill serve: Resilience_ Commercials__-_ Other <br /> Number of living units: Number of bedrooms <br /> F r <br /> Character of soif-to-a depth of 3 feet:- - Water table depth <br /> SEPTIC TANK Type/MfgCapacity) �' AC No. Compartments �- <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well,,� Foundation f� Property Line .i <br /> LEACHING LINE X No. & Length of lines —Z e Total length/size <br /> FILTER BED ❑ Distance to nearest: Well '245", Foundation�— Property Line <br /> SEEPAGE PITS Depth e su` -Si,,��� 'e Number <br /> SUMPS ❑ Distance to nearest: Wellr <br /> .j O® Foundation��� Property tine <br /> DISPOSAL PONDS ❑ <br /> s1 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 th-e 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 suis-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 s II for all required ins ctions. omplete drawing on reverse side. t--- <br /> Signed Title: _f�(R• Date: .J <br /> FOR DEPARTM T USE ONLY 7 / <br /> Application Accepted by Date ! Area r J�9q <br /> CP <br /> or Grout Inspection by Dat -� Final Inspection ate U <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 828-7104 ❑ Tracy 835-6385 041 <br /> Applicant- R'gturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT RE iT-rEED S � RECEIVED BY DATE � PERMIT-NO. <br /> + EH 13-24 1REV.101931 .0 N V1 `"� �,. Q�,.^,41,k <br /> EH 1429 y E V}4 /� 4f ? A tFl <br />