Laserfiche WebLink
i <br /> APPLICATION FOR PERMIT t� <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 /> Job Addr k - _ City 9 -b Lot Size PM <br /> Owner's Na i Wd ess � Phone i <br /> Cantracto rAddress License No. M Phone <br /> TYPE OF WELL/PUMP: NEW WELL 1-1WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK�­_f-." 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 /> 171 Industrial El Open Bottom ❑ Manteca Dia. ¢f Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private LI Gravel Pack 1-1Tracy Type�of Casing Specifications <br /> Q Public ❑ Other/ 1, •LlDelta"' T Deptfi of Grout Type YAe of Grout <br /> ❑ Irrigation ___4pprox: Depth ❑ Eastern Surface Seal Instialled by <br /> Repair Work Done ❑ Type of Pump.. — H.P. State Work Done � <br /> Well Destruction ❑ Well Diameter .Sealing Material {top 541 <br /> Depth Filler Material {Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ll DESTRUCTION <br /> o§optic system permitted if public sewer is <br /> �. 'available within. et./ <br /> -...�.,....-�„°,- a fe �„ <br /> Installation will serve: Residence_ Commercial_ Other , <br /> Number of living units: Number of bedrooms <br /> f <br /> Character of soil to a depth of 3 feet: Water able depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity • No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> i <br /> SUMPS ❑ Distance to nearest: Well Foundation Property tine <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' ignature 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 ner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I c ify that in the performa f the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Califor ' <br /> The applican fo all req ns. m tete rawing ra — <br /> Si Title: Date: <br /> R DEPARTM T USE 011iLY <br /> Application Accepted by i Date Are <br /> Pit or Grout Inspection by'_.- <br /> Date Final Inspection by Date <br /> rY,� <br /> Additional Comments: �c <br /> ❑ Stk 466-6781 't ❑ Lodi -3621 EVManteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE " <br /> - INFO AMOUNT DUE AMOUNT REMITTED , CASH RECEIVED BY w GATE PERMIT'NO. <br /> + EH 13-24(11EV.1/e sl b_IZ3 <br /> EH 14.28 <br />