Laserfiche WebLink
7 <br /> f <br /> APPLICATION FOR PERMIT r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 456-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NC7� <br /> (Complete in Triplicate) ��n r ; <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descri e�ication 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 /> Job Address r�L c� � _ — City Lot Size PM <br /> I' <br /> ;i Owner's Name Address g Phone V—e <br /> Contractor � 03142-4CAddress ase i , G t 1lilLLd License N Phon as <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> �l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL T PROBLEM AREA CONSTRUCTION SP IONS �s <br /> le <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Diaof cavation Dia. of Well Casing <br /> I <br /> ❑ Domestic/Private ❑ Gravel Pack © Tracy pe of Casing Specifications > <br /> ['1 Public F1 Other ; Cl De Depth of Grout Seal E Type of GrouE . <br /> I I Irrigation _..Approx. "De Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type p H.P. State Work Donee_ <br /> Well Destruction _ ell Diameter Sealing Material (top 50') <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTIO INo septic system permitted if public sewer is s <br /> available within 200 feet.) <br /> n Installation will serve:, Residence_� Commercial_ Other <br /> Ci <br /> Number of living units: Number of bedrooms _ <br /> i Character of soil to a depth of 3 feet: M ' r` Water table depth <br /> SEPTIC TANK- %❑ Type/Mfg I Capacity—.,f No. Compartments r <br /> PKG. TREATMENT PLT.`[] ,,. �. Method of Disposal <br /> Distance to nearest: Well r Foundation Property Line <br /> f w r <br /> , <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Cl 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. I <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 i <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 /> is <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 applica ust call for all required 'ns coons. Complete drawing on reverse side. a <br /> P _ Signed Title: Date: <br /> F1 DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> r <br /> Pit or Grout Inspection by Date 1 Final Inspection by = Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 C Manteca 823-7104 0 Tracy 835-6385 ° <br /> .I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFOFEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. 1 <br /> + EH 1321(REV.1,115) �C�U` Q IJ73�t'c� <br /> EH 11-26 <br />