Laserfiche WebLink
APPLICATION FOR-PERMIT S•r4�j <br /> 1++•i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT� ``� +® <br /> T 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781A �p�� �� ;: 3 <br /> PERMIT EXPIRES 1 YEAR FRO SUED 2��y ��► ; " <br /> (Corrtpl Jrtlii lic „y .. <br /> ,Q �� �/ 3 4_ 9 <br /> Application is hereby made to the San Joaquin Local Health District for a p� ® r t d <br /> It `the work he" <br /> des`Iribed7This application is <br /> made in compliance with San Joaquin County.Ordinance No. 549 for sewage or r rt eller nd the Rules and 6jegr4laSiens of the San Joaquin <br /> Local Health District. 9 J 9 tiWA <br /> s <br /> Job Address City Lot Si —_ PM <br /> Owner's NameAddress G r Phone T <br /> Contractor Addres License Ne. Phone4&_j'0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El <br /> 64 4� <br /> PUMP INSTALLATION �' SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <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 [A-fracy Type of Casing Specifications <br /> 171 Public n Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation �_Approx..Deptk7 J 1 Eastern Surface SeaLinstalled by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 { `� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [:] REPAIR/ADDITION 1 I DESTRUCTION I 1 fNo septic system permitted if public sewer is V� <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other Q <br /> Number of living units: Number of bedrooms <br /> Character of 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. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line �J) <br />-: -.w 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: "1 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." l <br /> The applicant must call far wired inspections. Complete drawing on reverse side. <br /> Signed X Title: Datr �� <br /> FOR DEPARTMENT USE ONLY <br /> '' <br /> Application Accepted by Date `'fir )02 F � Area <br /> Pit or Grout Inspection by Date Final Inspection by Date S'14 <br /> wi. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 . <br /> Applicant - Return all copies to: Environmental Health PefmiUServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> g <br /> FEE ASH <br /> AMOUNT DUE, AMOUNT REMITTED GK RECEIVED BY DATE PERMI7'NO. <br /> �Q <br /> Cy <br /> INFO <br /> f,EH 13-24(REV,i H sl �-r�� 46-1 <br /> EH N-25 <br /> r <br />