Laserfiche WebLink
APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED/k_7 <br />i <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br />Local Health District. <br />Job Address <br />....1 _. <br />,/ <br />Owner's Name /Vl7R!✓t A AWA A� Address - Y Phone 0 <br />Contractor's Name License No. Phone <br />TYPE OF WELL/PUMP: <br />NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PERMIT"N0. <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ v. OTHER ❑ <br />DISTANCE TO NEAREST: <br />SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, k <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />❑ Domestic/ Private <br />❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />❑ Public <br />❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br />❑ Irrigation <br />—Approx. Depth ❑ Eastern Surface Seal Installed by <br />Repair Work Done ❑ <br />Type of Pump H. P. State Work Done <br />Well Destruction ❑ <br />Well Diameter- Sealing Material (top 50'1{ <br />Depth Filler Material (Below 501 <br />TYPE OF -SEPTIC WORK,,,NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br />vailable within 200 feet.► <br />Installation will serve: <br />Residence _ Commercial Other <br />Number of living units: <br />Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />❑ Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />❑ No. & Length of lines Total lengthlsize <br />FILTER BED <br />❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS <br />❑ Depth Size Number <br />SUMPS <br />❑ Distance to nearest: Well Foundation Property Line ` <br />DISPOSAL PONDS <br />❑ <br />J <br />1 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 employ persons subject to workman's compensa- <br />tion laws of California." <br />The applicant must call for all required inspections. Complete drawing on reverse side. <br />Signed Title: 41 Date: <br />FOR DEPART ENT USE ONLY % <br />Application Accepted by`/`� Date /! Area <br />Pit or Grout Inspection by Date Final Inspection by Date <br />,AgAtional Comments: <br />Stk 4W-6761 ❑ Lodi 368-3511 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br />App ant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 07 <br />EH 1324 (REV. 10163) <br />EH 14-26 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />RECEIVED BY <br />DATE <br />PERMIT"N0. <br />% <br />