Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TION AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I,� <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> 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 Address01 <br /> city Lot Size PM r <br /> Owner's Name i. j Address I� ea, <br /> Phone r` <br /> y' 7`a coo <br /> Contractor's Name _ <br /> TYPE OF WELL/PUMP: cense No. <br /> If: NEW WELL ❑ WELL REPLACEMENT ❑ Phone l <br /> PUMPiINSTALLATION ❑ DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTiiC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES � DISPOSAL FLO. <br /> FOUNDATION AGRICULTURE WELLPROP. LiNE <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> E2 Industrial <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom �� y <br /> ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Wel! Casing <br /> ❑ Public i Type of Casing <br /> ❑ Other ❑ Delia Specifications <br /> ❑ irrigation Depth of Grout Seal <br /> --Approx. Depth ❑ Eastern Type of Gout <br /> Repair Work Done ❑ Type ofd Pump Surface Seal installed by ' <br /> Well Destruction ❑ H'al P. State Work Dane <br /> Well Diameter <br /> Sealing Material (top 50') <br /> Depth 1� Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION �a septic system permitted if public sewer is , 4 <br /> Installation will serve: Residenci e Commercial_ Other available within 200 feet.} i <br /> � { <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity. No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line <br /> LEACHING LiNE ❑ No. &i Length of lines t <br /> FILTER BED ❑ DistanMce to nearest: Well Total length/size fi <br /> °IM� <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depths: <br /> SUMPS S1ZB <br /> ❑ DistalNumber <br /> a to nearest: Well t <br /> DISPOSAL PONDS ElI Foundation Property Line <br /> I hereby certify that I have prepared�ihis 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 <br /> certifies the following. "I certify that in the performance of the work for which s rm t is issuedof 'I shall empfornia." loy per is hiring or csub-contracting signature <br /> tion laws of California." !` Pe <br /> employ persons subject to workman's compensa- <br /> tion <br /> applica m call for all required inspections. Complete drawing on reverse side. <br /> Signed �h <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Y 3 _ J <br /> / <br /> Pit or Grout Inspection by Date Dater a <br /> L' <br /> Final Inspection by Date <br /> Additional Comments: I�. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Envir6nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE <br /> INFO AMOUEREMITTMEDRECEIVED BY 'DATE <br /> EH M24 ` � ,////j PE IIT'sNO. <br /> EH 1426fREV.10/R:iY /O /To .'�� /_ L/ tY T- <br />