Laserfiche WebLink
. 11 <br /> APPLICATION FOR PERMIT 5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f 1681 E. HAZELTON AVE., STOCKTON, CA <br /> ! Telephone (289) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) l <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. .�k <br /> YO City �dt' le (.�M <br /> Job Address <br /> es hpne <br /> Owner's Name 9D` <br /> Contractor Address �� License I {Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION,���� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 11�.--fit' SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ON <br /> ❑ Ind -al ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavatiq,lL� Dia. of Well Casing <br /> ,mastic/Private ravel Pack ❑ Tracy Type of Casing Specifications 1:2 <br /> i <br /> f'1 Public n Other F1Delta Depth of Grout Seal ��� l Type of Grout <br /> rrigation Q "Approx. Dept I Eastern +�Surface Seal Installed by - <br /> Repair Work Dore- 0 Type of Pump c H,P. << State Work Done <br /> � . <br /> Well Destruction 1-1Well Diameter y"'�-`-Sealing Material {top 501 <br /> Depth Filler Material iBelow 50'1 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION l 1 (No septic system permitted-if-.public sewer is <br /> available within 200 feet.) <br /> t-: �_Installation-will-serves Residence Commercial Other- <br /> Number of living units: Number of bedrooms <br /> f Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TYR, Mfg Capacity No. Compartments 1 <br /> PKG. TREATMENT PLT. 0 Method ofDisposal <br /> u, Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE `0r ' No. & Length of lines Total length/size <br /> FILTER BED yam" 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE`PITS I'] Depth Size 'Number <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, <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 of California." <br /> �- The applicant must call for all required inspec. n . Complete drawing on reverse side. / <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY '} 0 1//F <br /> Application Accepted by .Date Area <br /> Pit or Grout Inspection InDate 3 91 inspection b Date 2r <br /> /] <br /> I r <br /> Additional Comments: f <br /> i <br /> 0 Stk 466-6781 0 Lodi 369-3621 ❑ anteca 823 7104 Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED �. CASH , RECEIVED BY _PATE h PERMITNO. <br /> INFO <br /> + EH 13-241REV.t/H5f <br /> EH 14-2e <br /> I <br />