Laserfiche WebLink
APPLICATION FOR PERMIT <br /> u SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r V 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> "k 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 fora 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 /> Xob Address ",Woi�C dY10r Ge �� City Lot Size PM <br /> (\Owner's Name Address Phone <br /> f-Contractor `/ �/L Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER KOLA-OF SFy V16F-W �1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />! <br /> 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 /> 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — <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 /> I Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> C Depth Filler Material (Below 50') _ q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> j 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 /> 4 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 Foundation Property Line <br /> I <br /> SEEPAGE PITS I 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 /> 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 applicant musts all <br /> for all required inspections. Complete drawing on reverse side. <br /> I Signed X T Title: Date: l �� <br /> f <br /> PARTMENT USE ONLY_ <br /> i <br /> Application Accepted by /� o-- 1M,-� Date -1y— Lo Area <br /> f Pit or Grout Inspection by Date Final Inspection by ` / Date <br /> Additional Comments: L freta` q!C SS ? 30 L IA✓/ ( fewer f, <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- <br /> 64 <br /> f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., .0. Box 2009, Stk., CA 95201 <br /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> a.EH 13-241REV.1/N51 <br /> EH 14-26 00,00 S 0.0o ,� 3 /Y,ga 7 570 <br />