Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f 1601 E. HAZETON AVE., ySTOCKTON, CA <br /> i Telephone 1209} 466-6781 <br /> 0,04 <br /> r PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> I {Complete in Triplicate} <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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 /> I C�l" t"j�r c <br /> Job Address <br /> J r�V 1/V.�-J V G���� ��- City �+ +6L:W0A/I of Size ,� PM <br /> Owner's Name. <br /> � D n.l; JAA'ddress /t/ � � � �- Phone <br /> Contractor Ad fti F I Address License No. Phone <br /> TYPE OF WELL/PUMP: a.NEW WELL WELL REPLACEMENT ❑ DESTRUCTION LJ b, <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J� <br /> ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( fl <br /> f ❑ Industrial„ Open Bottom D Manteca Dia. of Well Excavation_ t <br /> Dia. of Well Casing' <br /> Type Of.Casin ACTiC_ Specifications — <br /> Domestic/Private �I�,YGravel Pack ❑ Tracy Yp g <br /> k f`1 Public F1 Other Delta Depth of Grout Seal 3 Type of Grout - <br /> I l Irrigation -Apprgx. Depth l I Eastern Syrrface Seal installed by <br /> i 11 State Work Done <br /> Repair Work Done Ll Type of Pump H.P. <br /> Well Destruction [I Well Diameter ­-- <br /> Sealing Material (top 501 <br /> Depth `Y ,,,,.Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI DESTRUCTIO d (No septic system permitted if public sewer is <br /> available within 200.feet.) <br /> t <br /> r Installation will serve: Residence ercial_ Other <br /> F ' F <br /> ' Number of living units: Number of bedroo <br /> Character of soil to a depth of 3 feet:' I. Water table depth <br /> SEPTIC TANK '❑ Type/Mfg acity !i'No. Compartments <br /> PKG. TREATMENT PLT. ❑ ! �'. Method of Disposal <br /> Distance to nearest: Well ounda Prop'erty,Line <br /> length/size <br /> .LEACHING LINE r°❑ "No. & Length of lines tal len� w g <br /> FILTER BED vi ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS r l I Depth Size Number ' <br /> SUMPS a Ll Distance to nearest: W l Foundation Property ne <br /> DISPOSAL PONDS ❑ i M`� .i <br /> I hereby certify that ad t have preparethis application athat the work will be done in accordarice with San Joaquin <br /> d county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or 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 /> F 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 <br /> :r <br /> The a licant mu or all required inspections. Complete-drawing on reverse side. „ <br /> Signed <br /> Title: � <br /> FO EPA-�KTMENT USE ONLY <br /> Application Accepted by "w Date Area O <br /> Pit or Grout nspection bye, Date �d Final Inspection by .� Date " <br /> Additional Comments: <br /> Fina <br /> Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 r41 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY: -.;: DATE PERMIT NO. <br /> INFO J-- <br /> l +.Eli 13-24(REV.t/h 51 <br /> d S D7c -32Z <br /> r EH t4-28 <br /> t <br />