Laserfiche WebLink
i <br /> i <br /> Ile APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,.STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7; r ,(Complete in:Triplicate) .r4 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.'TNs application is <br /> made in compliance with San Joaquin County Ordinance No-549 for sewage or No. 1.862 for well/pumpand the Rules'and Regulations of the San Joaquin <br /> Local Health District. <br /> 01 <br /> l 1 <br /> Job Address City Lot Size PM <br /> Owner's Name r - Address �� <br /> 1 Phone <br /> 7 <br /> Contractor J Address a License No. R Phone / 93 <br /> TYPE OF WELL/PUMP: NEW WEL'02 WELL RE15LACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> PRO <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE IONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of xcavation_ Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Graver Pack ❑ Trac Type of Casing Specifications <br /> ❑ Public ❑ Other Delta Depthvof Graut Sear — T,ype:of*(reset-��•,, <br /> - <br /> ❑ Irrigation pprox.':Depth ❑ Eastern Surface Seal Installed by .� <br /> Re air Work O e <br /> p T e of Pum H.P. _ <br /> Yp P State Work Dane <br /> Well ruction ❑ ' Well piameter Sealing Material (top'50') ; <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (Na septic system permitted if public sewer is <br /> t{ available within 200 feet`) <br /> Installation i <br /> a ation will serve: Res,dence Commercial <br /> --� Other <br /> Number of living units: Number of bedrooms <br /> a <br /> Character of soil to a depth of r3 feet:I Water table depth: <br /> SEPTIC TANK ❑ TIe/Mf <br /> YP g Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line 1 <br /> LEACHING LINE ' ❑ No. & Length of E nes Total length/size <br /> 6i <br /> FILTER BED ❑ Distance t' n � - ` <br /> o Barest: Well Foundation <br /> Pres Line <br /> — � perry <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPSD Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 certifier 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 f all required i ct" nt. Complete drawing on reverse side. <br /> Signed X 1 <br /> 9 Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> 1 �y <br /> Application Accepted by Dat�7­ Area L <br /> Pit or Grout Inspectia Date Final Inspection by Date �� .s <br /> i <br /> Additional Comments: <br /> ­L7 5tk466 678 T❑ Lodi 369-3621p Manteca 7104 Tracy ,83f85 <br /> ..,. <br /> Applicant Return afl copies to: Environmental Health Permit/�rvices 1601 E. Hazefton Ave., P.O. Bax 2009, 5ik., CA 9x201 <br /> i <br /> FEE ---AMOUNT DUE,' AMOUNT REMITTED`' a "r' 'RECEIVED BY DATE PERMIYNO. f <br /> —INFO�.. "CASH I <br /> rr ` <br /> + EH 13-241REV.ties, _ -0Q Q� 1 <br /> EH 14-28 I ` <br /> 6 <br />