Laserfiche WebLink
APPLICATION FOR PERMIT <br /> yr <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA G <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) / <br /> Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> r 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. 11 f <br /> r , <br /> Job Address / x <br /> i City C Lot Size lk <br /> PM <br /> -Owner's Name _,L Ll1l�,(� r�'� ddressLtAf t Phone <br /> " Contractor Address License No. &pP Phone <br /> TYPE OF WELL! MP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ <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 /> I 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 1 <br /> F1 l Public ❑ Other F7 Delta Depth of Grout Seal Type of Grout _. <br /> �! <br /> I I Irrigation —._Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump <br /> H.P. State Work Done_ <br /> F Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depthr Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION {.l : DESTRUCTION f o septic system permitted if public sewer is <br /> I vailable within 200 feet.) <br /> Installation will serve: Residence '_# Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feei� Water table depth <br /> f SEPTIC TANK LJType/Mfg Ca acit <br /> p Y No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> rr-�., <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 kine <br /> SEEPAGE PITS I'] Depth Size Number n{ <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ A i <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; "I certify that in the performance of the work for which this permit is issued, I shall <br /> tion laws of California." t em pto <br /> y persons subject to workman's compansa- <br /> 1 I <br /> The applicant must call for alll required i specti s Complete drawing on reverse side. <br /> Signed C"r Title: z <br /> Date: <br /> FO _DEPARTMENT USE ONLY <br /> Application Accepted by "�, � 7 <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> , Date � 7 <br /> Additional Comments: r f <br /> ❑ 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. Bax 2009, Stk., CA 95201 <br /> •1 h <br /> FEE AMOUNT DUE AMOUNT REMITTED i <br /> INFp �7 CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH t3-24 IREV,i i n 5) ,y57O. <br /> EH 1425 ti✓VVV _ (�7L_,� �•/.�f 07—t4EA <br />