Laserfiche WebLink
APPLICATION FOR PERMIT <br /> * SAN JOAaUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> �k1 PERMIT EXPIRES TYEAR FROM DATE ISSUED 3 <br /> t <br /> (Complete in Triplicate) <br /> Appli <br /> all the work <br /> n described.This <br /> cation is <br /> madein(on is eieby made compliance with San oJoaqu nnCoungty Ord nanee No. 549 for sewage or uin Local ealth District for a permit <br /> 1862 for well/dpump and the Rules and 1Regulationss of the Sans Joaquin <br /> Local Health District. <br /> hCity 5'tQCJSkoJ Lot Size PM <br /> Job Address <br /> 5 , 0 .-So �n <br /> J� Owner's Name � Address Phone <br /> Contractor_.� Address ' <br /> License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELT. ❑ , WELL REPLACEMENT EJ DESTRUCTION El <br /> 1°. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP, LINE <br /> A 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 /> r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public ❑ Other F Delta Depth of Grout Seal Type of Grout—.— <br /> I <br /> rout I I Irrigation _—Approx. Depth t 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 <br /> Depth Filler Material (Below 501 <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l t , DESTRUCTIO (No..septic system permitted if public sewer is <br /> 11 available within 200 feet.) O <br /> I Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms I _ <br /> Character of soil to a depth of 3 feet: _Water table depth (� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. C1; Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines - Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 /> 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 compansa- <br /> tion laws of California." <br /> The applicant Rust call for all re ired inspections. Complete drawing on reverse side. <br /> Signed X ^ �7�►`f`'e Title: Date: �7 <br /> FOR DEPARTMENT USE ONLY <br /> Area ` <br /> Application Accepted by Date <br /> 1 Pit or Grout Inspeption byDate Final Inspection by Date <br /> A�d itional Comment§: <br /> At466-6781 ❑ Lodi 369-3621 ❑ Manteca 823- 04 E) Tracy 835- 5 <br /> A''�plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> r + EH 13-24(REV,i i K 51 � UQ <br /> EH I4-2a ✓J <br />