Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> ti PERMIT EXPIRES TYEAR 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 compliance with San Joaquin County.Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San"Joaquin <br /> Application <br /> Local Health District, T I <br /> I 563 r—, IeS'h city Sri` Lot Size PM <br /> 3 J.VAddr855 1 <br /> I r1 r��JT _ /Y7 1 Phon '1t ",0 <br /> ner's Name <br /> p n Address <br /> Contractor Own eQ Address License No. Phone_ <br /> TYPE OF WELLIPUMP: 74 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A ICULTURE VffiLlr OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS1 <br /> ❑ industrial ❑ Open Bottom ❑ ca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> I ID Domestic/Private ❑ Gravel Pack Tracy Type of Easing Specifications — <br /> 1-1 Public 1-1Other l 17 Delta Depth of Grout Seal Type of Grout <br /> I I irrigation ApSA <br /> prox, Depth [ I Eastern urface Seal installed by— <br /> I <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction ClWell Diameter t Sealing Materia top 50'1 <br /> Depth r) Filler Material (Below 501 <br /> + TYPE OF SEPTIC WORK: NEW INSTALLATION I I. REPAIR/ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is <br /> I{ y ailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> t F <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 Meet: Water table depth _ <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> l <br /> PKG. TREATMENT PLT. ❑ �� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8�Length of lines Total length/size <br /> t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> r SUMPS L-i Distance to nearest: Welt -Foundation Property Line �, <br /> DISPOSAL PONDS Cl 1 <br /> hat the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that i have prepared this application and t <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 /> tt 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 theivin-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 <br /> J/required <br /> //inspections. Complete drawing on reverse side. �7 <br /> \- `t1ft.� '�` Title) C3��ALaA.. <br /> Signedc Date, <br /> r '� !� <br /> //////��`��` <br /> :rDEPAIRITMIENT USE ONLY �{ <br /> Application Accepted by ` Date ` Area <br /> Pit or Grout Inspection by Date Final inspection by Date <br /> I<r Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: EAvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> lie <br /> INFO AMOUNT DUE AMOUNT REMITTED C 8H ti RECEIVED BY DATE PERMIT'NO. <br /> I + EH 13-24(REV.1 i n 5) <br /> EH 14-26 <br />