Laserfiche WebLink
. . . . . . . . . . . . . - P <br /> 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 /> (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. <br /> r_ �{41 <br /> Job Address City e-G Lot Size�Sl PM <br /> -_ - <br /> Owner's Name r_-__ Address Phone <br /> ,..Contractor_ � <br /> � � Address �-- --License No: — Phone.. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1:1DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial IJOpen Bottom. C1Manteca Dia. of Well Excavation Dia. of Well Casing <br /> # ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> L ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Da�ne <br /> -.„ � 9 <br /> Well Destructia T ❑ Well Diameter' Sealing Material {top 501 <br /> i <br /> Depth Filler Material (Below ') <br /> I TYPE OF SEPTIC WORK: NEW INSTAL TION ❑ REPAIR/ADDITION DESTRUCTION❑ INo septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> I Installation will serve: Residence_ Commercial— Other <br /> Number jof living units: Number of bedrooms" <br /> Character of soil t, a depth=bf 3 feet: �►Ld� �O A✓n ^-- Water table depth <br /> SEPTIC TANK ❑ Type%Mfg! t Capacity `" No. Compartments <br /> i PKC. TREATMENT PLT. 71j Method of Disposal + <br /> Distance to nearest: Well Foundation Property Line <br /> ----------- <br /> t <br /> LEACHING LINE No. & Length of lines Topil length/size <br /> FILTER BED ❑ Distance to nearest: Well_511 — oundation — Property Line <br /> SEEPAGE PITS ❑ Depth Size Number` <br /> SUMPS ❑ 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. <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 warkmar}'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,.l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all re uired inspections. Complete drawing on reverse side. <br /> Signed Title: _ Ae Q Date: <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> t Date Area <br /> Application Accepted by r. CJ, <br /> Pit or Grout Inspection by Date 'Final Inspection by Date �J <br /> k + <br /> e <br /> Additional Comments: <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 83546385 +. <br /> Applicant- Return all copies to: Environmental Health Permit/Sekices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201,x, <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO /S <br /> + EH 13-24(REV.t/85) ^ L <br /> EH 14-28 L�L� — <br />