Laserfiche WebLink
APPLICATION FOR PERMIT <br /> + SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> }: Telephone (209)-466-6781 ; <br /> r PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hetaby 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 /> Job Address 1 J ��°ti City r <br /> Lot Siz <br /> .� l <br /> Owner's Name - i Address - <br /> )w4— Phone <br /> } Contractor Address ,°} License No.J f�j Phone_$ 2 <br /> TYPE OF WELL/PUMP: NEW WELL,❑ WELL REPLACEMENT ❑ l DESTRUCTION 171. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.'LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ..TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 4 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack 11Tracy Type of Casing Specifications <br /> FI Public ❑ Other ❑ Delta - Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth l 1 Eastern Surface Seal installed by <br /> r. <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction C1 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material iBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> t available within 200 feet-1 <br /> Installation will serve: Residence` Commercial a ,�„ f n <br /> Number of living units: Number of bedrooms s 0 d <br /> f Character of soil to a dept Mfg of 3 feet: •Water table depth v 1 <br /> I <br /> SEPTIC TANK Type/ Capacity No. Compartments 2 <br /> PKG. TREATMENT PLT_❑' A .,, r Method of Dispo'sa <br /> Distance to nearest: Wel! Foundation - Property Line <br /> g . <br /> LEACHING LINE o. 9,iength-of lines �` ^' ' `-`� Total length/size <br /> r t"I - .t .. -�- --- - <br /> FILTER BED Distance to nearest: Well Foundati <br /> El Property Line <br /> ,- <br /> SEEPAGE PITS >f h Depth Size Number <br /> SUMPS a ❑ Distance to nearest: Wel! Foundation f Property Line <br /> DISPOSAL PONDS .❑ �A <br /> I hereby certify that I'have prepared this and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, and <br /> rules and regulations'of the San Joaquin Local Health District. <br /> f 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,l shall employ persons subject to workman's compensa- <br /> tion laws of California." 101 . Ill , <br /> The applicant must tail for all re ired inspections. Complete drawing on reverse side. <br /> Signed X � Title: oca. .e}r Date: 20� <br /> i FOR..DEPARTMENT,USE-ONLY <br /> �` � y <br /> Application Accepted by -_'-0ate Area <br /> Pit or Grout Inspection by Date Final InspectioDa <br /> Additional Comments; <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> kApplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> +t FEEAMOUNT DUE AMOUNT REMITTED C <br /> INFRECEIVED BY DATE PERMIT'NO, <br /> ft O <br /> 4 _ <br /> + EH 13-24 IREv. <br /> EH 14-26 � <br />