Laserfiche WebLink
f <br />APPLICATION FOR,PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone 1209) 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 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 />Local Health District. •} r-- 1 <br />Job Address <br />19 <br />`�"r <br />Owner's Namee� <br />/ Phone <br />.01 <br />A 1F ` Phone C l22 <br />Contractor's Names r�� <br />- ,cense No. <br />TYPE OF WELL/PUMP: <br />NEW WELL ❑ WELL REPLACEMENT ❑ D UCTION ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ A, <br />DISTANCE TO NEAREST: <br />SEPTIC TANK( SEWER LINES DISPOSAL FLD. PROP. LINE.. <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />❑ Domestic/ Private <br />❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />❑ Public <br />❑ Other I ❑ Delta Depth of Grout Seal Type of Grout <br />El irrigation <br />---Approx. Depth 1-1EasternSurface Seal Installed by <br />Repair Work Done ❑ <br />Type of Pump _ H. P. State Work Done <br />Well Destruction ❑ <br />Well Diameter Sealing Material (top 501 <br />Depth I Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: <br />Residence Commercial _ Other <br />Number of living units: <br />' Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg Capacity No. Compartments <br />PKG: TREATMENT PLT. <br />❑ } Method of Disposal <br />' <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />❑ No. & Length of lines Total length/size <br />FILTER SED <br />❑ Distance to nearest: Well Foundation Property Line <br />t <br />SEEPAGE PITS <br />❑ Depth l Size Number <br />SUMPS <br />❑ Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS <br />Fl t <br />Q5 <br />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." Contractors 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 call all required innssjppeecction�s. Comp) awing on reverse side. <br />Signed . /" /� _ Title: Date: 1 7 —,1 <br />FOR DEPARTMENT USE ONLY Q <br />Application Accepted by Date, ' `/� `-'V Area 0 1 <br />Pit or Grout Inspection by { �- Date Final Inspection by%—.�rY s Date <br />I 1 <br />Additional Comments: <br />❑ Stk 466-6781 = Lodi 369-3621 ❑ Manteca 823-71W ❑ Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />FEE AMOUNT DUE' AMOUNT REMITTED %CILDRECEIVED BY DATE PERMIT`N0. <br />INFO CASH <br />+ EH 13-241REV. 10189) 4I5 <br />EH 14-26 1 <br />l � <br />