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 k <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 /> p Local Health District. ' <br /> Job Address , <br /> i r City Lot Size �PM <br /> Owner's Name <br /> =Address e <br /> v : + Phone "+ <br /> Contractor. Address ` r. 4� <br /> r4 License No. <br /> TY <br /> f i PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 9 <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. _ PROP. LINE _ <br /> FOUNDATION GRICULT RE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE ARE CONSTRUCTION SPECIFICATIONS y <br /> ❑ Industrial . .❑ Open�:Bottom ❑ Mantec Dia- of Well Excavation k <br /> f Dia. <br /> E] Domestic/Private ❑ Gravel Pack F] Tracy Type <br /> WeA Casing <br /> of Casin 1Specifications <br /> 1'1 Public f7 Other ;CI Delt Depth of Grout Sealy ' <br /> I I Irrigation < - "r t! `! "" Type of-Grout----- _ <br /> J ; k: * r'f, *..Approxi Depth I Ea rn q Surface Seal fnst211ed by <br /> Repair Work Done ❑ f Type of Pump +- N..P: ' " f �'" <br /> - ' o State,Work <br /> 0 Well,De'tructton ❑ Well Diameter 'S, =' v <br /> afng 1lllaterial`ftop 50') <br /> Depth 1 Fillet Material iBe <br /> TYPE OF SEPTIC WORK: 'NEW INSTAL ATION I:] RFPAIR/ADDITION._ y`DESTRUCTION IIrfNo septic system ermitted if <br /> ,available within 200 feet.) public sewer is <br /> [ Installation will serye: Residence._ Commercial Otheri_ ` l <br /> Number of living units: Number of bedr s <br /> Character of soil to a depth of 3 feet: I <br /> Water table depth <br /> SEPTIC TANK D Type/Mfg <br /> i <br /> PKG. TREATMENT PLT. El -.Ca ity No. Compartments r <br /> ! t Method of Disposal <br /> Distance to nearest: Well Foundation'h <br /> Property Line <br /> r'< t <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDT t' length/size <br /> ❑ Distance to nearest: - Well oundation <br /> # r— Property Line <br /> SEEPAGE PITS [ Depth Size I <br /> SUMPS ;Number <br /> ❑'Disdaton. <br /> tance to nearest: well Founi . <br /> ` DISPOSAL PONDS ❑�� � _ Property Line <br /> 4 C' <br /> .. { <br /> I hereby certify that I have,prepared this:application and that the work will be donein accordance with San Joaquin county ordinances, state laws, and v <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner ar,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 /> 1 fi employ any person in such manner as to.become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature r <br /> certifies the following: "I ceriiiy that in the,performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- , <br /> tion laws of California." ,} <br /> The applicant ust cal! all 'red inlspections. Complete drawing on reverse side, r <br /> Signed X <br /> Title: t <br /> Date: <br /> f <br /> 1 F DEPARTMENT USE ONLY <br /> P _ <br /> Application Accepted by1/ <br /> Date 4, Area <br /> Pit or Grout Inspection b <br /> e Final Inspection by�i , <br /> Date <br /> Additional Comments: "I <br /> ❑-Stk 466-6781 ❑ Lodi-369-3621{{.`,.� 0 Manteca-823-7104--El-Tracy,-,,835-,6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 EHazelton Ave., O. Box 2009, Stk., CA 95201 Y ` <br /> FEE ' AMOUNT DUE' r� AMOUNT REMITTED CK F <br /> INFO CASH RECEIVED BY DATE <br /> PERMIT'NO. s <br /> +.EH 13-241HEV.iiHSY <br /> EH 14-28 <br /> r 1 <br />