Laserfiche WebLink
a APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 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 /> 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 /> a. <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. n <br /> Job Address 00 '✓ z Ci Lot Size PM <br /> ' !f0 00 6 Phone pf0 <br /> Owner's Name Address <br /> ' i ss License No. Q�112 Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: W WELL❑ -WELL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> t <br /> } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom ❑ Manteca_ Dia. of Well ExcavAtion Dia. of Well Casing <br /> ❑ Domestic/Private <br /> 1-1GravelPack ❑ Tracy Type of Casing Specifications <br /> F] Public Cl Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .Approx. Depth I I Eastern I�Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. i State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth 'Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [] REPAIR/ADDITION I I DESTRUCTION Mo septic system permitted if publi'c sewer is r; <br /> *I available within 200 feet.) i <br /> Installation will serve: Residence_ Commercial_- Other F <br /> Number of living units: —Number of bedrooms <br /> j` Character of soil to a depth of 3 feet: Water table depth <br /> ' SEPTIC TANK ❑ -Type/Mfg Capacity No. Compartments 4 1 f k <br /> ..-PKG. TREATMENT PLT. © 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 /> �lll SEEPAGE PITS I 1 Depth Size _ Number I „ <br /> SUMPS D 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must c 11 ctions. Complete drawing o reverse side. ' <br /> w <br /> Signed'X Title: — Date: l s <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �kJ <br /> Date 'y Area ✓1 fi v <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by I <br /> Additional Comments: <br /> 0 Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 <br /> Applicant - Return all copies 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 ..Ik <br /> . DATE PERMIT NO" <br /> INFO - <br /> + EH 13-24 IRM' <br /> i/A5Y <br /> EH 14-29 - <br />