Laserfiche WebLink
f <br /> APPLICATION FOR PERMIT <br /> f SAN JOAO.UIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I PERMIT EXPIRES 1' EAR FROM DATE ISSUED y <br /> II <br /> (ComP14 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 Ryles and Regulations of the San Joaquin <br /> Local Health,District. -7 h- g 1 1 <br /> Job Address 0--3 � City Lot Size PM <br /> h <br /> I al ' . . .. - — <br /> Owner's Name _ gc`-=Ze Address _ }-Phone <br /> Contractor. Address License No Phone <br /> TYPE OF WELL/PUMP:. �A NEW WELL ❑ .�WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> V-V?\PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE,TO NEAREST: SEPTIC-,TAW, n - wSEWER LINES DISPOSAL FLD. PROP. LINE <br /> Ip FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- <br /> El Industrial 1a ❑ Open Bottom t ❑ Manteca y',•� Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack ;�,❑iTracy Type of Casing Specifications l <br /> ❑ Public d ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ig ---Approx. Depth O Eastern Surface Seal Installed by <br /> Repair Work,Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 1 <br /> I� Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> I _ Y available within 200 feet.) <br /> Installation will serve: Residence 1�Commercial_ Other <br /> Number of living units: Number of bedrooms i` t <br /> Character of soil to a depth of 3 feet;• Water table depth I <br /> SEPTIC TANK ❑ Type/Mfg i•tx r~' eh "Capacity No. Compartments ; <br /> PKG. TREATMENT PLT.-i7. ; ` x^^o^ Method of Disposal°, G <br /> # Distance`to neatest d <br /> We- � �s S Founcisiion '- ! Property Line <br /> LEACHING LINE W'-'No. & Length of lines "" ��"®� Total 1erPgth/sife"�9 <br /> FILTBED <br /> ER ❑ I Dista .W <br /> Distance to nearest: well Foundation Property Line F <br /> r <br /> SEEPAGE PITS ❑N Depth Size Number ± # <br /> r <br /> 1� t �,tl Pro SUMPS R � � El to�ne�rest:.� Well Foundation r!` A 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 <br /> pules and regulations�af the San"Joaquin Local.Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance o#`the workfor which this permit is issued, I •shall not - <br /> employ any'person in such manner.as to become subjecH6 workman's compensation laws of California",Contractor's hiring orisub-contracting signature <br /> r <br /> certifies the following: "I certify,that in the performance of the work for which this permit is issued,I shail�Wploypersons subjecf to workman's compensa- <br /> iion laws ofpCaliforhia." I # ( 3 t <br /> r The applicant must call for all quire spections. Complete drawing on reverse side. F? ` <br /> Signed t a Title: Date: t <br /> I) i FOR DEPARTMENT USE ONLY <br /> pplication"Accepted by t ` Date �T f Area p - <br /> ) AAIO� /�` / <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: { <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant-`gReturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . <br /> - -�.-.• --4- -*r'[�FEE— AMOUNT DUE AMOUNT,REMITTED RECEIVED.BY DATE- PERMIT'NO.' <br /> CASH ?.: -+'EN13-24(REV.�5�5) 'r <br /> EH 1428 l ` <br />