Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE_ STOCKTON, CA <br /> Telephone (209) 466-6781 I <br /> PERMIT EXPIRES 'i 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 Na. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> VV i 74-4I7e- City Lot Size PM <br /> Job Address 1 <br /> Phone <br /> Owner's Name CZk (I. <br /> fair Address <br /> u�1r1 <br /> l) License No. v Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT. 0DESTRUCTION ❑ I' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR'i❑ OTHER ❑ <br /> } I <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION r AGRICULTURE WELL t OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _.Dia-of-Well-Easing, _--- <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I <br /> - <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ? ❑ Tracy Type of Casing . -Type of Grout - <br /> FI Public ❑ Other ❑ Delta Depth of Grout Seal <br /> I 1 Irrigation Approx. Depth l 1 Eastern Surface Seal Installed by - <br /> Woik-Done <br /> Repair Work Done ❑ Type of Pump H P --- -State r � <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth <br /> r Filler Material (Below 50'1 x <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,* •REPAIR IADDITION I I DESTRUCTION-I I (No septtiilablec systthiem <br /> rmi ted if public sewer is <br /> eet <br /> Installation will serve: Residence A Commercial— Other <br /> Number of living units: Number of bedrooms_C—_ .,, ~; <br /> JAY ms U Water table depth <br />, ., Character of soil to a depth of 3 feet: <br /> SEPTIC TANK LO Type/Mfg <br /> 0-1 <br /> r Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest; Well Foundation Property Line <br /> f f ) <br /> LEACHING LINE :' No. & Length N <br /> of lines ota! lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well � — Foundation Property.Line <br /> SEEPAGE PITS IQI Depth, Size Number �7 <br /> SUMPS ❑ Distance to nearest: Well -.' Foundation Property Line <br /> ,— DISPOSAL-PONDS ❑ <br /> ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work w <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 /> mpensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become subject to workman's co <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 must call for ail required ins lions. omplete drawing on reverse side. <br /> r Title: _ �-t� Date: <br /> Signed <br /> I OR DEPARTMENT USE ONLY <br /> IDate / w !1_ Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date Jf <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. Hezelton Ave., P.O. Box 2009, Stk., CA 45201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> +.EH 13-24 MEv.v/nsf <br /> I EH 14-26 <br />