Laserfiche WebLink
r <br /> APPLICATION FOR PERMIT J <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> C Telephone .(2091 466-6781" <br /> 1 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 1 <br /> i C <br /> 33 <br /> Job Address Lot Size PM ; <br /> hone <br /> 4 Owner's Name Address P , <br /> Contractor JAddress 3 p 3S¢ 3 91 F `License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 1-1 WELCREPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _ 4. SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 1'. -AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF-WELL i, PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ._Dia. of Well Excavation Dia. of Well Casing ' w <br /> ❑ <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications- — <br /> k M Public M Other C-1 Delta Depth of Grout Seal Type of Grout <br /> — - <br /> i I Irrigation _.-Approz"De'p`th IYI�Eastern Surface Seal installed by t� <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter �.-. � Sealing Material atop 50'i y� <br /> Depth Filler Material i6elow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ! REPAIR/ADDITION IJ DESTRUCTION iNo septic system permitted if public sewer is <br /> available within 200 feet.) V� <br /> Installation will serve: Residence"t. Commercial Other r. <br /> Number of living units: Number of bedrooms <br /> " i Water table depth l <br /> Character of soil to a depth of 3 feel: C__ <br /> SEPTIC TANK ElType/Mfg I" Capacity No. Compartments V <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Dista n I to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size \� <br /> FILTER BED ❑ Distance to_nearest: Well Foundation Property Line �S <br /> r SEEPAGE PITS l I Depth Size Number II <br /> SUMPS ❑ 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. i <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." Contractors hiring or sub-contracting signature <br /> r 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." I <br /> r- The applicant must call for all required inspections. <br /> /Complete drawing on reverse side. <br /> Signed X . Title: Date: <br /> - �-- . <br /> --�-�FQR-DEPARTME11iT USE--UNL-Y-+ - <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection Date Final Inspection by ✓✓ Date <br /> Additional Comments: . <br /> v ice[G <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CK ID RECEIVED BY DATE PERMITNO. <br /> EH 1324 1 REV.1/H <br /> - - EH 14-26 - --- <br />