Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r <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 1 <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 /> I <br /> Local Health District. t <br /> ve� � rt� / City '� Lot Size PM <br /> Job Address k <br /> Phone Z t g ; <br /> Owner's Name J• O v Address _ <br /> �f - "kLv7 So <br /> ��� �, C�t Address �• License No. C� Phone <br /> .2 <br /> Contractor�-- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ tDESTRUCTION_ i <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 /> ❑ Industrial ❑ Open Bottom 71 Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ public ❑ Other Cl Delta Depth of Grout Seal <br /> Type of Grout <br /> I I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done17 <br /> _ j <br /> Sealing Material [to 50'IrSQ� �f�{e �r�{r <br /> Well Destruction ❑ Well Diameter g p � <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I l a ailableo septtic systemithin rented if public sewer is <br /> Installation will se esidence_ Commercial Other <br /> r Number of living units: umber of bedrooms <br />' Character of soil to a depth 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: Well ation Property Line <br /> LEACHING LINE ❑ No. & Length of lines engthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prop Line <br /> SEEPAGE PITS l 1 Depth Size Number <br /> I SUMPS Lli 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 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 o ifo►nia." <br /> V <br /> The appiic nt m far a14 requi d inspec' s. Complete drawing on r arse side.Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY _ <br /> Application Accepted by <br /> 2 z Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 11 Me <br /> 623 7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S*., CA 95201 <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO _ <br /> t EH 1 <br /> 3-24(REV.1/8 51 �S <br /> EH 1428 <br />