Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I 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. t� h' `` <br /> Job Address j / -' T Cit !+ Lot Size 6-,� PM <br /> Owners Name "` " Address `�J T JC Phone <br /> Contractor _- 1 Address License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> O Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> f l Public C; Other p Delta Depth of Grout Seat W Type of Grout <br /> Irrigation —Approx. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done L Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter _ Sealing Material ([op 56'} ~r <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION .1 REPAIR/ADDITION ! ) DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK u Type/Mfg CapacityNo. 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 BED ❑ Distance to nearest: Well Foundation _ Property Line <br /> SEEPAGE PITS I I Depth Size Number�. <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 Di§trict. <br /> Home owner or licensed agent's signatu a ifres the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in7.' <br /> ma er as to me subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the follow, : cerci thatIrformance of the work for which this permit is issued, I shalt employ persons subject to workman's compensation laws at Celif ni <br /> The applicant m call for/t, requitions. Complete drawing on reverse side. <br /> SignedX r� � Title: Q46-A''G�Z Date: 6 S �� <br /> ` c� FOR DEPARTMENT USE ONLY t <br /> Application Accepted by ` T �� Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: AVL �—& t .— _, �.� set_ �1� ~ 1 it <br /> C Silk 466-6781 It Lodi 369-3621 C Manteca 823-7104 C Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1661 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO <br /> FEE AMOUNT DUE AMOUN��T RR�EMITTED CK CASH RECEIVED BY DATE PERMR'NO. <br /> -Es 13-24 IREV. 51EH 14 26 MRS <br />