Laserfiche WebLink
1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> E <br /> (Complete in Triplicate) <br /> i <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 /> C 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 /> A <br /> Job Address City Lot Size "�` PM <br /> Owner's Name <br /> Address Phone <br /> 2 . <br /> Contractor AZ Z Address_(fie' eV A License No,? Phone <br /> TYPE OF WELL/PUMP; ; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t PUMP INSTALLATION 11 " SYSTEM REPAIR ❑ OTHER ❑ # <br /> ji DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE t <br /> q FOUNDATION AGRkCUITURE WELL OTHER WELL PITS/SUMPS I <br /> r 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 /> Li Public ❑ Othe t Ll Delta Depth of Grout Seal Type of Grout <br /> ­ <br /> I i Errigation .�Approx. Depth I I Eastern Surface Sea)`installed by 1 <br /> Repair Work Done ❑• Type of Pump H.P. .'Statq Work Done I r� <br /> Well Destruction CI Well Danheter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 ) f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIR/ADDITION DESTRUCTION I 1 iNo septic system permitted it public sewer is <br /> available"within 200 feet.) ; <br /> Installation will serve: Residence*<" Commercial_ Other r <br /> Number of living units: Number of bedrooms !9L . I <br /> r Character of soil to a depth of 3 feet: Do Bol Water table depth <br /> SEPTIC TANK Y Type/Mf _ r CapacityL No:"Compartments �. <br /> r PKG. TREATMENT PLT. ❑ { f 1: - 7— Method of Disposal <br /> 2 Distance to nearest: Wel Foundation 3� _l'� Property Line a i-- <br /> LEACHING =No. &"Ler9 <br /> th of�lines �` ' O r <br /> �S —��� ' Total length/size <br /> FILTER BED j ❑ Distance to nearest:. �, ;WellIk Foundation F'. l. Property Line <br /> SEEPAGE PITS I I Depth s Size Number ' r <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS.»- =L� <br /> hereby certify that I have prepared..this'applic`ation and that the work will be done in accordance with San 3oaquin_couhty'ordinances, state laws, and <br /> i rules and regulations of the San Joaquin Local Health District. t;r .,�. ti ` �* <br /> y Home owner or licensed agent's signature certifies the following:I certify that'lm the.perform'�nce of the work for which this permit is issued, k shall not <br /> . employ any person in such manner as to become subject to workniar'6-compensation lawsrof'California." Contractor's hiring br sub-contracting signatureil <br /> certifies the following: "I certify that,in the performance of the work for ydhtch this permit is issued;1 shat)employ persons subject to workman's compensa- <br /> tion laws of California:' <br /> Thea applicant must call for all re uired ins <br /> PP q pectioris. Complete drawing on reverse side. <br /> Signed X Tote: ' i' <br /> Date:' <br /> R PIEPARTMENT USE ONLY <br /> A Ircation .-� <br /> PP Accepted P b Y - Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date, <br /> Additional Comments: <br /> G <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantec,3• '82377104 ❑ Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE' { <br /> f <br /> INFO AMOUNT DUE ' AMOUNT.REMITTED '� CASH �.n RECEIVED BY GATE l PERMIT"NO. <br /> + EH13.24 IREV.I/H 57 5/ <br /> EH 1428 / <br />