Laserfiche WebLink
APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA lull! <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED •�►��� <br /> (Complete in Triplicate) <br /> r 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 City Lot Size - QM <br /> _ Phone <br /> Owner's Name _ A�d^dr�es-s, <br /> Contractor � „+`� Address t^-�L�� I�" License No.➢' -�� hone �T <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 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT S/SUMPS <br /> t 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 /> fl Public F1 Other 171Delta Depth of Grout Seal Type of Grout - <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> r <br /> Repair,Work Done- ❑ Type of Pump H.P. State Work Done _ <br /> A`Ytilefl:Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> { a available within 200 feet.) <br /> Installation will serve: Residence- — Commercial_ Other-., - _ F <br /> i Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ` Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 1, No. Compartments <br /> PKG. TREATMENT PLT. ❑ t # Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS El Distance to nearest: 1 Well Foundation Property tine <br /> DISPOSAL PONDS ❑ <br /> 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 /> i 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." I ` <br /> Theapplicant mu call f r all re qu'a inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FO DEPAR11�TMENT USE ONLY Q� <br /> Application Accepted by Data . Area <br /> Pit or Grout InspecliC by Date Final Inspection by { - Date <br /> Additional Comments <br /> ❑ Stk 466-6781 odi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 <br /> r Applicant - Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO ^��� <br /> * E H 13-24{REV.I/N sl ,J t1 �S 'C_�(.3 It !rU <br /> p# EH 14.29 - J <br />