Laserfiche WebLink
..,tea--.�......�..M _ _ ... <br /> �giCA­tION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> p application is <br /> App, and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work herein described.This app <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump <br /> Local Health District. �:� <br /> City Lot Size PM <br /> Job Address _ <br /> r` � ' —N � �,r�(ZQ��[j�i _� Phone <br /> Address -�1 �� <br /> Owner's Name f <br /> Contractor Address <br /> fig License No.C ra Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11 <br /> zSEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST:SEPTIC TANK -- AGRICULTURE.WELL-.- - OTHER WELL± -=± PITS/SUMPS �- -- <br /> FOUNDATION, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pl��l Specifications <br /> Industria! Pack Type of Casing <br /> �- -- _ <br /> ❑ Domestic/Private Gravel k ❑ Tracy c Depth of Grout Seal Type of Grout <br /> C <br /> L1 Other l Delta <br /> M Public Surface Seal installed by <br /> __Apprax. Depth l 1 Eastern — <br /> I�Irrigation ,It of Pum H.P. State Work Done <br /> Repair Work Dane LJ Type ,p Seating Material {top 50'1 <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material (Below 501 <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRIADDITION l DESTRUCTION l i available septic <br /> ailabllewi hin 200 feeittted if public sewer is <br /> IIristallatiori will serve: Residence Commercial _ Other <br /> '+ -Number of living units: Number of bedrooms- Water table depth , <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> k SEPTIC TANK ❑ Type/Mfg <br /> ' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property.Line <br /> Distance to nearest: Well Foundation. <br /> 4 <br /> I <br /> Total length/size <br /> LEACHING LINE ❑' No. & Length of lines Property Line <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> Number <br /> SEEPAGE PITS 1 I Depth Size T <br /> Foundation Property Line. <br /> ! SUMPS LI Distance to nearest: Well _. _ <br /> DISPOSAL PONDS ❑ <br /> j 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 /> I . 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, 1 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 /> r Certifies the following: u 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 appli t ust call for all re ired inspect ons. Complete drawl on re id <br /> r 5Title: Date: — <br /> Signed X <br /> FQR D TMENT USE ONLY <br /> 1 Date �" - Arga <br /> Application Accepted by <br /> Pit or Grout Inspection by Date— - Final Inspection by Date <br /> Additional Comments: 5-6385 <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 83 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> O 1 <br /> +-EH 13-24(REV.5/e 5) INFO <br /> F EH t4-28 <br />