Laserfiche WebLink
i <br /> I <br /> APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address CSL <br /> Phone <br /> Owner's Name^' - Address <br /> a6 le qz!ce Phone <br /> Contractor's Name License No. <br /> TYPE OF WELL/PUMP: NEW WELL 11 WELL <br /> LACEMENT ❑ DESTRUCTION E3 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 8' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ,Er Domestic/Private EJ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ,K Irrigation ---Approx. Dep Easternk Surface Seal Installed by <br /> Repair Work Done EDType of Pump .H.P.- ' State Work Done <br /> Well Destruction (IWell Diameter Sealing Material (top 50') , <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system <br /> m rented if public sewer is <br /> ava.� <br /> Installation will serve: Residence_ Commercial— Other r <br /> r Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TAMC ❑ TypelMfg`-" 4 •Capacity W No. Compartments <br /> ,' + ' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line <br /> . .., r <br /> LEACHING LINE ❑ No. & Length of lines 4 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well - Fo ndation Property Line <br /> t <br /> SEEPAGE PITS ❑ Depth Size Number wry <br /> 'SUMPS C] Distance to nearest: Well-• Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> 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:pplicajoust call all required inspections. Complete drawing on arse side.Signd X—�� '� Title: Date: <br /> 1 <br /> FO DEPARTMENT SE ONLY �j D <br /> Application Accepted by Date r�'v Area <br /> Pit or Grout Inspection by <br /> Date Fin I Inspection by Date C <br /> Additional Comments: <br /> {[ ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 /> FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED-BY DATE PERMIT"NO. <br /> INFO C <br /> + EH 13-24(REV.101831 <br /> EH W26 <br />