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 <br /> ( ` (Compiete 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. .• :,: <br /> �7 / Oil ', e�,t �!p-�-�- !�/v <br /> I Job Addre YL� t L ��iC/O 44)i 4 1.b �j'�+!yr R� <br /> City Lot Size <br /> PM <br /> Owner's Name �d� <br /> dress l Phone <br /> Contracto ! Z' �- <br /> Address License N <br /> TYPE OF WEL UMP NE WELL ❑ Phon <br /> WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAY f?f <br /> DISTANCE TO NEAREST: SEPTIC TANK � OTHER ❑ , <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL i �" <br /> OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing' <br /> ❑ Tracy Type of Casing <br /> ❑ Public ❑ Other Specifications , <br /> ❑ Delta Depth of Grout Seal <br /> ❑ irrigation �pprox.1Depth ❑ Eastern Type of Grout <br /> t Surface Seal Installed by 1 <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well:Diameter' State Work Dane <br /> Sealing Material (top 50') . <br /> Depth Filler Material (Below 50') �•;✓` <br /> TYPE OF SEPTIC WORK: N <br /> I W INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION EI (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 /> Charactef­of soil'to a depth of-S-feet:» <br /> SEPTIC TANK ❑ Type/-Mf g"'�" '��� - -. '':i <br /> Water table depth <br /> Capacity^�-_. No. Compartments <br /> PKG. TREATMENT PLT. ❑ 4' i `:.;° i <br /> f. x Method of Disposal <br /> Distance to nearest: i 1 Well Foundation <br /> Property Line <br /> ` LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED Total length/size r <br /> ❑ Distance to nearest:'4 Well;. . Foundation <br /> w Property Line <br /> SEEPAGE PiTS ❑ Depth Size <br /> SUMPS ❑ Distance tolnearest: Well Foundation Number <br /> DISPOSAL PONDS ❑ �,.i Property Line <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. <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 .l shall not <br /> employ any person in such manner,-as to become subject to workman's <br /> certifies the following: ' � compensation laws of California."Contractor's hiring or sub-contracting signature <br /> g: "I certify tKat 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 lifornia." ? <br /> i <br /> The applic t all fo all r ui a inspections. Complete drawing on reverse side. / t <br /> Signed / ov <br /> yyr i <br /> it Date: <br /> } <br /> FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by'.. t <br /> Date - -' Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ 5tk 456 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 <br /> Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. CA 95201 <br /> ' 1 , # <br /> FEE <br /> INFO ?;AMEOUNT:DU7E AMOUNT REMITTED CASH RECEIVED BY DATEo PERMITN0. <br /> EH 13-24 1REV.1/135) ��f <br /> EH 3428 I <br /> 1 <br />