Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA 1 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D <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 welltpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> tn ��{ I 7 <br /> Job Address �"` — ' Ci Lot Size �� 1tC //� PM <br /> Owner's Name ress Phone <br /> / p3 <br /> Contractor z&b Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LJER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI L FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS `\ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ;11 Mantec Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specificationsf'1 Public n Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _A Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ e of Pump H.P. State Work Done <br /> Well Destru ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION { I DESTRUCTIONIX (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to aepth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: ell Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L1 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. 1_ <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, 1 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 s call for all re fired i coon . Complete drawing on rave side. <br /> ' <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date `~� Area <br /> �2 <br /> Pit or Grout Inspectio Date Final Inspection Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 3-7104 ❑ 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 <br /> INFO AMOOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT*NO. <br /> tEH1324IREY.1/nsl 2ecr <br /> [lcl f' Lc4 -Zan <br /> EH 14-26 <br />