Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he+eby 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 Cou Ity 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 <br /> �,Q ��N, p� City Lot Size PM <br /> �7 �•� � <br /> Phone <br /> Owner's Name � <br /> y'S �.A i(,C'�'� Address <br /> Contractor;— Address -- �-�-JT nse No —A- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION d <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 1:1DISTANCE 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 /> *.d. trial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r Type of CasingSpecifications r <br /> ❑ Domestic/Private a Gravel Pack ❑ Tracy `V <br /> ll <br /> 1-1Other 171Delta Depth of Grout Seal = Type of Grout <br /> Public <br /> I I Irrigation --.Approx.-Depth �l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. t State Work Done <br /> Well Destruction ❑ Well Diameter' Sealing Material Imp 501 <br /> Depth Filler Material l8elow 50'1 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I (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 a <br /> i Character of sail to a depth of 3 feet: ' Water table deet <br /> ' 44 <br /> Capacity r. No. C <br /> SEPTIC.TANK ❑ .Type/Mfg` I <br /> PKG. TREATMENT PLT:❑� Me44Wisposal <br /> Distance tonearest:—Well —»Foundation.—.propegy_Llne <br /> I - <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> t: Well Foundation Property Line <br /> FILTER BED El Distance to nearest: �ENVI 5NMM HEALTH <br /> I� SEEPAGE PITS I i Depth " Size _ Number <br /> SUMPS L1Distance to nearest: Well Foundation Property Line <br /> k <br /> DISPOSAL PONDS 13 t <br /> f <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, an <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." Contractors 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." I.' <br /> The applicant must qP11 foApIl required spections. Complete drawing on reverse side. , <br /> Signed Y - <br /> Title: Date:FOR ID ARTMENT USE ONLY �f <br /> Date Area <br /> Application Accepted by <br /> t Pit or Grout Inspection by <br /> Date Final Inspection by Date 2 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO ,�TJ Dl CAI= <br /> � <br /> + EH 13-241REV.5/x51 -3S[N v,[ �r� !~� V • ��✓� <br /> EH 14-28 <br /> t <br />