Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 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 /> Job Address City r Lot SizePM <br /> Owner's Name Address eEi5U_ _ ,rC O TTS hVePhone <br /> Contractor's Name 7UJ'19' -­S`6'/If License No. ;?-S 3{ "-3 V_-..? Phone `e'- 94�4D <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION - _..AGRICULTURE WELL. OTHERR-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 v- <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 501 <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— Other <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. ❑ _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 2.1-r�'' Foundation Property Line <br /> SEEPAGE PITS Depth zr <br /> .2 CJ Size �f Z Number <br /> SUMPS ❑ Distance to nearest: Well 2-1k� Foundation J7> 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. Y - <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 apJnAcGepted <br /> st call for all required inspectio Co plate drawing on reverse side. <br /> Signed 9 Title: ,� _ Date: I <br /> P "� "5� F R DEPARTMENT USE ONLY <br /> Applica by Date Area v <br /> Pit r Grout Inspection by ate ✓rte Final Inspection by <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 /> X, <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 <br /> CASH RECEIVED 8Y DATE PERMIT''NO. <br /> + EH 13-24 1REv.101 <br /> 831 1 i <br /> EH 14 l26 ^b <br />