Laserfiche WebLink
A ' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 i <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. <br /> Job Address _ 72V City Lot Size PM <br /> Z. <br /> Owner's Name A S. JA 1A) Address �~ L. / it ! L 7��� <br /> Phon <br /> 013�sS <br /> Contractor's Name 1) —4" 7fV_ License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ VA ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROF. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy-- - Type of Casing Specifications ' <br /> ❑ Public ❑ Other, ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> I <br /> Repair Work Done ❑ Type of'Pump H.P. State Work Done + <br /> I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW 1NSTALI5kTION ❑ "REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> j f I available within 200 feet.) <br /> Installation will serve: Residence_� Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a'depth of 3 feet: ` Water table depth <br /> SEPTIC TANK p Type/Mfg- Capacity No. Compartments i <br /> PKG. TREATMENTPL'T. ❑ Method of Disposal <br /> t <br /> .6,,,Distance to nearest: Well Foundation Property tine <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation .Property Line <br /> SEEPAGE PITS ❑ Depth Size_ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this.application a`nd 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: '=1 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ pentons subject to workman's compensa- <br /> tion laws of California." yy <br /> The applicant must call for all required ins tions. Complete drawing on r erre side. i <br /> SignedTitle: <br /> _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> at J <br /> Application Accepted by Date 7Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 7--Lfy <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> EH 13-24/REV,101831 ! � <br /> EH 1428 CC//ld �if I <br />