Laserfiche WebLink
�,- APPLICATION FOR PERMIT `. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 „ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED.T I <br /> (Complete in Triplicate) <br /> q p application is F <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work he <br /> described. This app <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. c { , ,, 'C ; <br /> Job Address .= Cit <br /> Lot SizeCLCLG� <br /> Owner's Name <br /> !/ /� Address Phone <br /> Contractor Address License'No. Phone <br /> TYPE OF WELL;PUMP: NEW WELL E7WELL REPLACEMENT ED <br /> ❑ <br /> PUMP INSTALLAT SYSTEM REPAIR ElOTHER ❑ <br /> N C3 <br /> ipSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS <br /> ' INTENDED USE TYPE OF WELL PRD LEM AREA NS7RUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom [E] Ma <br /> Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ cy ' Type of Casing Specifications <br /> LD PubliciI <br /> Ll Other ❑ Delta DeptFi of Grout Seal Type of;Grout <br /> ❑ Irrigation ;, _—Appr . epth Ll em Surface Seal Installed by <br /> H P. ' State Work Done <br /> Repair WorkDone ED] Type o Pu'l <br /> mp <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 1 p� <br /> Depth' Filler Material IBelow 501) V" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) ' <br /> Installation will serve: Residence! Commercial a Other <br /> a <br /> Number of living units: Number of bedrooms r t ' <br /> Character of soil to a depth of 3 feet Water table depth <br /> I SEPTIC TANK EJ t. <br /> Capacity "6 No. Compartments <br /> 1 r Method of Disposal <br /> PKG. TREATMENT PLT. ❑ j <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ElNo. & Length of lines Total length/size <br /> + Property Line <br /> f FILTER BED ❑ Distanct)to nearest: - Well Foundation P Y <br /> SEEPAGE PITS ❑ Depth —Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line-' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> k 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 /> such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> employ any person in s <br /> certifies the following: certify that inLthe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- r <br /> tion laws of California." <br /> The applicant st for all required ' ti s. Co E drawing on reverse side. <br /> Y Title: <br /> Date: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Date z Z Area <br /> Application Accepted by <br /> Final Inspection by 'Date �U <br /> Pit or Grout Inspection Dat ; <br /> Additional Comments: <br /> ❑ Stk 466-6781ElLodi 369-3621 ElManteca 823-7104 171Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Petmit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 <br /> K RECEIVED L3Y DATE PERMYT NO, <br /> FEE AMOUNT DUEHC5ED C H <br /> �/7/�EH 13-24 MEV.I/n 5l v <br /> EH 14-28 <br />