Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone ( JX6JV'— _7Vz.0 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> fAplication 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 /> de 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 /> cal Health District. <br /> ao�7 w <br /> b Address City Lot Size PM <br /> ner's Name Addressq5Z3Phone <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: "'K NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION„❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PROP. LINE' <br /> FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C CTtON SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑Gravel Pack cy Type of Casing Specifications <br /> [-I Public F1 Other Ci Delta Depth of Grout Seal Type of Grout <br /> I I'lrrigation —..Appr Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of rump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter. Sealing Material [top 501 <br /> Depth - Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11. REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet I 1 <br /> Installation will serve: ResidenceCommercial_ Other ---moi <br /> Number of living units: Number of bedrooms <br /> t <br /> f Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ T <br /> ype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance 4o nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1-1 Depth ,.I Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that i have prepared this application and that the,work wilt 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 signal6re 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 tp become subject to workman's compensation taws 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." r <br /> The applicant must call for all retau'red <br /> 'inspections. Complete drawing on reverse side, n h or <br /> Signed X %,l`4 A tHk L&,:� n Title: ® `�� Date: <br /> V FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r2/–$'� Area <br /> ! /*w-Mrs- oww io '~ . 1 �F- <br /> Pit or Grout Inspection by Date (Final Insp ction by <br /> eT c. IAJ Eat <br /> Additional Comments: �' 1f( <br /> ❑ Stk 466-6781 ❑ Lodi 369-3421 O Manteca 823-7104 O Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E!Hazelton Ave., P.O. 200 tk., A 95201 <br /> { <br /> FEE AMOUNT DUE. AMOUNT REMITTED RECEIVED BY DATE PERMIT'ND. <br /> INFO <br /> f a EH 13-24 <br /> (REV. INFO <br /> y 51 � �' <br /> EH T4-28 cun <br /> E <br />