Laserfiche WebLink
APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j (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. F <br /> City Q41 1�..Lot Size PM <br /> Job Address .,�. <br /> Owner's Name —�� a` l Co S <br /> Address Phone <br /> �.� / Phone '17 <br /> Contractor's Name (cense No, _. <br /> TYPE OF WELL/PUMP: �E�VV �L� 71 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS <br /> l FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia, of Well Casing <br /> L] Industrial [I Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Tracy Type of Casing. Specifications <br /> El Domestic/Private ❑ Gravel Pack Type of Grout <br /> Ll Public <br /> ❑ Other I `s' Q Delta Depth of Grout Seal <br /> El Irrigation —Approx. ❑ Eastern Surface Seal Installed by <br /> H <br /> Repair Work Done L] Type of Pump <br /> P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth a Filler Material (Below 501 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (No'sbptic syst m permitted if public sewer isavle ' <br /> " Installation will serve: Residence Commercial— Other <br /> x a <br /> Number of living units: Number of bedrooms ! Water table depth <br /> Character of soil to a depth of 3 feet:, - No. Compartments <br /> SEPTIC TANK EJType/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ? x Property Line <br /> Distance to nearest: Well Foundation <br /> i t <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation E P Y <br /> t <br /> — Size Number <br /> SEEPAGE PITS ❑ Depth ° <br /> SUMPS ❑ Distance to nearest: Well <br /> Foundation. Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby-certify that 1 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 /> nsed 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 /> Home owner or lice <br /> employ any person.n such manner as to become subject to workman's compensation laws of California." Contractors 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 st call forII required inspect . Complete drawing on reverse side��_ �"�"'�J <br /> Title: Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by z <br /> Final Inspection by �' Dat <br /> e <br /> a Pit or Grout Inspection by Date - <br /> , <br /> Additional Comments:'• <br /> ❑ Stk 466 l ❑ Lodi 369-3621 ❑ Manteca 823-7104 ED Tracy 835 �{ <br /> Applicant- Return all copies-to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952U1 <br /> 1�- <br /> FEE CK# RECEIVED 9Y DATE PERMIT'N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-24(REV.10!83} •. �/(4� <br /> �S. �� <br />