Laserfiche WebLink
y .N <br /> =` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE4TON AVE., STOCKTON, CA e <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> : . ' <br /> i (Complete in Triplicate) <br /> lication.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 /> App n nty Ordinance No.549 for sewage or No. 1862for w:iupump and the Rules and Regulations of the San Joaquin <br /> made in compliant oouin Cou <br /> Local Health District <br /> l' Lot Size PM <br /> S. <br /> �A�h&a City <br /> Job Address, �.p� <br /> Phone <br /> Address ' <br /> Owner's Name Address <br /> ��3 Phone <br /> License No. <br /> I Contractor's NameDESTRUCTION L3TYPE OF WELLIPUMP: NEW WEL WELL REPLACEMENT <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION DISPOSAL FLD. PROP. LINE <br /> I SEWER LINES PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> FOUNDATION � �f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> 4 ❑ Open Bottom )(Manteca Dia. of Well Excavation <br /> i ❑ Industrial Type of Casing V Specifications <br /> Domestic/Private *KGravel Pack ❑ Tracy / Type rout <br /> Ll Other Q Oelta Depth of Grout Seal <br /> ` ❑ Public Installed by <br /> t <br /> Surface Seal Insar <br /> [:1 Irrigation <br /> ---Approx. Depth ElEastern H.P. State Work Done ri <br /> k Repair Work Done ❑ Type of Pump Sealing Material (top 501 <br /> i ^ <br /> Well Destruction ❑ Well Diameter Filler Material {Below 50'1 r <br /> Depth <br /> t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nailabpe�wit c sNstern feet.) if public sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> 1 Water table depth <br /> Number of living units: Number of bedrooms <br /> I Character of soil to a depth of 3 feet: CapaciNo. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. E3Distanceto nearest: Well ty Foundation Property Line <br /> t <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> 1 SEEPAGE PITS ❑ Depth <br /> Size Number <br /> SUMPS ❑ Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> k 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. ued, I shall notg work for this <br /> : 111 certify that in the Home owner olicensed in such manner as torbecome subjectolto workman s compensation lawsoof California.,'Cont actor's'hi hiring or sub-cont act ng signature <br /> i employ y Pe <br /> i 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 compen - <br /> tion laws of Cali ornia." <br /> The applica ust call for all requireld ins ions. Comple drawing on reverse i <br /> 1 Date: <br /> e: <br /> i Signed LAAO <br /> FO DEPARTMENT USE O <br /> I C Date Area v <br /> Application Accepted by <br /> F <br /> mrt�lev + Y + a Final Inspection by Date 0 <br /> Pit or Grout Inspection/by ` �t ! r <br /> { ' 6-11-V ViCrl}GnnI f prof G4 IIErl-s Yovfed b-� - <br /> Additional Comments: <br /> i ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835VM <br /> Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +EH 13-24[REV.101831 1 . V <br /> eu 1A- <br />