Laserfiche WebLink
00 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1C/56 <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 /> 4 <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 /> i517rIGit�o <br /> I Job Address City' t Size PM <br /> pcD�� <br /> Y/-,!P Ad 5� <br /> u Owner's Name _. . �_... .��? Address �7�� ,� �G»�t/� - Phone1101,74 <br /> .. ._. <br /> Contractor S .Address v�j � 10J4Ci) /License Na. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ Z. _ SYSTEM'REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION rAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca _r-Dia. of Well Excavation Dia. of Well Casing <br /> (11Domestic/Private ❑ Gravel Pack ❑ Tracy Type-'of Casing Specifications <br /> 171 Public, ❑ Other ❑ Delta Depth'of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I ] 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 (Sa Ateg _� _ <br /> Oept= Filler Material (Below 501 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/,ADDITION-LJ- DESTRUCTION l I. (No septic system permitted it public sewer is <br /> >4- 'L w.,= F available within 200 feet.) <br /> Installation-will-serve:=Residence��Commercial_=--Other - —� <br /> .Number of living units: Number of bedrooms + <br /> f <br /> 'Character of soil to a depth of 3 feet: Water table depth {p <br /> SEPTIC TANK ❑ Type/Mfg Capacity` ` "^ No. Compartments Q <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation ,Property Line <br /> f LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation [ Property Line <br /> SEEPAGE PITS I I Depth Size <br /> Number,-'.. 1 <br /> SUMPS L Distance to nearest: Well Foundation Property Line (� <br /> DISPOSAL PONDS ❑ '�•- <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, 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 /> 6 certifies the following: "I certify the#in the performance of the work for which this-permit is±ssued, I shall employ persons subject to workman's compensa- <br /> tioh`laws of California." ��� <br /> The apphcant_%WiX equir ns. Complete drawing on re rse de. <br /> Signed X r Title: Date: <br /> 'FOR DEPARTMENT USE ONLY <br /> Application Accepted by r Date ~ ' Area ' <br /> Pit or Grout Inspection by ' _ Date Final Inspection by Date <br /> Additional Comments: r- <br /> ❑ Stk 466-6781 ❑ Lodi,-369-3621 ' ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies-to: Emit or nrrtental Health Permit/.Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT RUE AMOUNT REMITTED CK 0 <br /> CASH RECEIVED BY DATE , PERMIT'NO. <br /> + EHt3-21(REV.1/n5Y 35 <br />