Laserfiche WebLink
i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i 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 fcr.sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.-. <br /> ' Job Address %orCity Lot Size PM <br /> t ' <br /> Owner's Name <br /> Addressr/ Phone J' Q <br /> Address 71J� License No. Phone <br /> Contractor �.-.--� <br /> 1 TYPE OF WELL/PUMP: NEW WELL ❑/ WELL REPLACEMENT DESTRUCTION ❑ <br /> I PUMP INSTALLATIONS SYSTEM REPAIR Cg' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION- GRICULTURE WELL, — �OTHER.WELLPITS/SUMPS _ <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Ind nal ❑ Open Bottom ❑ Mant a Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gfavel Pack racy Type of Casing Specifications <br /> Fl Public ❑ Other ',.1.. ❑ Delta Depth of Grout Seal Type of Grout . <br /> I I I Irrigation _._Approx. Dep I Eastern Sjorface Seal installed by _ <br /> - Repair Work Done El Type of Pump H.P. 1!!Z2 State Work Done <br /> Well Destruction L] Well Diameter Sealing Material (top 501 <br /> iDepth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIWADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence. Commercial_ Other <br /> I - 4 <br /> Number of living units: Number of bedrooms <br /> ' Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r.1 <br /> r <br /> LEACHING LINE ❑ No. &:Length of lines Total length/size <br /> I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line J� <br /> 1 <br /> • SEEPAGE PITS C I Depth I Size Number <br /> t SUMPS; ❑ Distance to nearest: Well Foundation Property_Line, �. .. .__ ... <br /> f DISPOSAL PONDS ❑ 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 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. c� <br /> Signed X Title: Date:li <br /> FO DEPARTMENT USE ONLY <br /> Q <br /> Application Accepted by Date ;A, Area <br /> Pit or Grout Inspection by Date Final Inspection by Date -2 <br /> Additional Comments: <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. Box 2009, Stk., CA 95201 <br /> i , f <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> tH 13-241 , r,r� <br /> •.EN1�ZatpEV.rinsl '�-lj� t p0 �t�f G,-0 <br />