Laserfiche WebLink
ova' <br /> I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 7/°�9A.)- <br /> i 1601 E. HAZELTON 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 <br /> Joaquin County Ordinance No. 549 for sewage or No. 1862 forwell/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District: + <br /> r <br /> �AA10 ' City '�'` '',' Lot Size r PM <br /> Job Address <br /> Address Phone <br /> Owner's Name. f <br /> i a <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL El <br /> REPLACEMEN DESTRUCTION- 171 <br /> PUMP INSTALLATION ❑ SYSTEM REPAT❑ OTHER)4 0"A--kS2eA11CJe1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑.Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Grave( Pack ❑ Tracy Type of Casing 'Specifications <br /> Type of Grout <br /> n Public FI Other 71 Delta Depth of Grout Seal YP <br /> i I Irrigation ' —..Approx. Depth i I Eastern Surface Seal Installed by <br /> - Repair Work Done. ❑ Type of Pump H.P. State Work Done— <br /> r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth ,1 Filler Material (Below 50') <br /> i <br /> f TYPE SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> I available within 200 feet-i 4 <br /> I, installation will serve: ence` Commercial'_ Other <br /> Number of living units: u., f bedrooms <br /> + Water table depth <br /> i Character of soil to a depth of 3 feet: <br /> SEPTIC TANK IDType/Mfg Capacity- No. Compartments <br /> PKG. TREATMENT PLT. L1 . Method of Disposal <br /> f Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ ..No. & Length of lines Total length/siz <br /> FILTER BED ❑, Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I') Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> I 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 /> y 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 /> f tion laws of California." <br /> i The ap ca t must c ail re Or d ins tions. Comps a drawing on reverse side. /J <br /> Title: Date: 7 <br /> Signed <br /> FORD PARTMENT USE ONLY <br /> Application Accepted by Date Area �(L <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <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 /> ki A <br /> { FEE AMOUNT DUE AMOUNT REMITTEDSH RECEIVED BY DATE PERMIT'NO. <br /> r _ INFO �f <br /> t EH 13-241REV.i/R5f <br /> EH 14-26 <br />