Laserfiche WebLink
APPLICATION FOR PERMIT �J�] <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTr 1 / <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781c� <br /> l� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a <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 Address ` City_ Lot SizeZ.Z �e�t PM <br /> Owner's Name �� � Address Phone <br /> Contractor's Name License No. &2 ` Phone , <br /> i TYPE OF WELL/PUMP: NEW W LL ❑ 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 J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump IA.P. - - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 <br /> Depth Filler Material (Below 501 ]--"- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo 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 t0_6 depth of 3 feet: - Water table depth <br /> i �tJC'at°CfE No. Compartments <br /> SEPTIC TANK �' Type/Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ s , Method of Disposal <br /> Distance to nearest: Well Foundation ZO X 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 2- <br /> SUMPS Distance to nearest: Well Foundation ZO �� Property Line 3 <br /> DISPOSAL PONDS ❑ <br /> 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 of California." _ 1 <br /> The applicant m II fo all requ" d inspections. Complete drawing on reverse sr <br /> 4 Signed <br /> Title: Date: <br /> FOR TMENT USE ONLY <br /> k- Application Accepted by Dlite <br /> Date 7�� Final Ins action by �-• f�Ca� <br /> k Pit or Grout Inspection by r p y <br /> r Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 -�L] Tracy 8354KM <br /> �• Applicant- Return all copies to: Environmental Health Permit/Services.1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED BY DATE LPERMIT'NO.' <br /> INFO CASH <br /> 5 + EH 1324(REV.10183) <br /> EH 14-28 <br />