Laserfiche WebLink
f I <br /> i . APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZEL T ON.AVE., STOCKTON, CA. <br /> Telephone (209) 466-6781 <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 /> t ' <br /> Job Address iT + � City Lot Size If r X PM <br /> Owner's Name /A) Address 36 6A, - Phone <br /> l� <br /> I� <br /> � Contractor's Name v License No. �� 7a` Phone 3 <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 /> I. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r. IE INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f <br /> Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ✓] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Q Irrigation _--Approx. Depth' ❑ 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 d1 <br /> III Depth f Filler Material (Below 501, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ✓ Vr available within 200 feet.) <br /> Installation will serve: Residence= Commercial_ Other I <br /> Number of living units: --L Number f edrooms ^ <br /> Character of soil to a depth of 3 feet _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg a'Capacity No. Compartments <br /> I PKG. TREATMENT PLT. 1­71 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> l <br /> LACHING LINE &---N—,. & Length of lines f d Tc'Sfal length/size � <br /> FILTER BED 11 Distance to nearest: Well Foundation r! Property Line �® f <br /> SEEPAGE PITS Q--Depth r�L c5 f Size 3 r _ Number - <br /> SUMPS i1Y Distance to nearest: Well��'�Foundation �Ca Property Line <br /> DISPOSAL PONDS ❑ , . <br /> Il hereby certify that I have prepared this application and that the work will be done ri'accdrdance 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 compensetion,laws of California."Contractor's hiring or sub-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 /> ton laws of California." <br /> I- <br /> T" <br /> he applicantoust call f I r quired inspections. Complete drawing on reverse side. <br /> Signed ) Title: . Date: <br /> f j <br /> FOR DEPARTMENT USE ONLY. <br /> i <br /> pplication Accepted by S Date Area <br /> I �I or Grout Inspection by Date Final Inspection by_fiF / <br /> _. <br /> Additional Comments: 013_ u=_ <br /> D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental,Health-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEEO AMOUNT DUE!�` AMOUNT REMITTED CASH RCK J ECEIVED BY DATE PERMIT`N0. <br /> EH13.z4(REV.10t8315. a <br /> EH 1428 <br />