Laserfiche WebLink
f <br /> 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 /> (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. J� <br /> Job Address q k1, 1 �'C-� City r Lot Size <br /> Owner's Name Address 0-4��Phoone <br /> Contract Address 6L 76 License No. 329y ` ..Phone (d 10S <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE v ` <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> T_ _❑ Public. ❑ Other.. ❑ Delta Depth of Grout Seal, Type of Grout <br /> ❑ Irrigation ---ALpprox. Depth ❑ Eastern 'Surface Seal Installed by <br /> Repair Work-Done ❑ Type of"Pump 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 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Others`' <br /> Number of living units: / Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> , , f <br /> SEPTIC TANK &-'Type/Mfg Capacity Ak4L No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> dat <br /> Distance to nearest: Well_.�b _ Founion-­-70- Property Line S <br /> ` a <br /> LEACHING LINE No. & Length of lines Q r "" Total length/size a Q it <br /> I� FILTER BED ❑ Distance to nearest: well Foundation-/[3 Property Line.�s <br /> SEEPAGE PITS ❑ Depth i Size Number k- <br /> SUMPS ❑ Distance to nearest: Well -' Foundation ropertj Line <br /> DISPOSAL PONDS ❑ -'"" "" T ~ <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 certifies the following: "I certify that in the performance of the work for which this permit is issued, L 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 m t call for alLrequired inspections. Complete drawing on revere side. <br /> Signed Title: P Date: 10 <br /> FOR DEPARTMENT USE ONLY <br /> Z. Z <br /> Application Accepted by �— Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <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 <br /> V0 sk" A1,03 <br /> + E 13-241REV.F/B5) C) •+ O <br /> EH 14-26 <br />