Laserfiche WebLink
r <br /> 4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Q r � <br /> ` (Complete in Triplicate) U <br />} Application is hereby made to the San Joaquin Local Health District fora _ <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 forcwell/dpump and the Rules and egnstall the work herein described. <br /> ations of the San Joaquin <br /> Local Health District. <br /> Job Address l SCity [car t Size ¢ C.. <br /> PM <br /> Owner's Name Address 1 <br /> Phone f �~D ` <br /> Contractor 5Address 3?- G /, <br /> icense No. S��, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> • PUMP INSTALLATION LJ SYSTEM REPAIR LJ OTHER ❑ 5 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> 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 <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation Jq Type of Grout <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H p <br /> State Work Done <br /> Weil Destruction ❑ Well Diameter <br /> Sealing Material {top 50'} <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AD DESTRUCTION ❑ !No septic system permitted if public sewer is <br /> a <br /> Installation will serve: Residence-X- Commercial-�_ Other available within 200 feet.) <br /> �E <br /> Number of living units: _,L Number of bedrooms -:3 I <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of bisposaI <br /> Distance to nearest: Well _ Foundation Property Line <br /> LEACHING LINE No. & Length of lines _L _ Total length/size t <br /> FILTER BED ❑ Distance to nearest: Well <br /> . t —�� Foundation_%�� � property Line Z Z�•«s- <br /> SEEPAGE PITS ❑ Depth z- j Size 3 (� Number <br /> SUMPS ❑ Distance to nearest: Well <br /> 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."Contractors hiring or sub-contracting signature <br /> certifies the following: "1 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." <br /> The applicant must call for al required inspections. Complete drawing on reverse side. '} <br /> Signed Title:_ ..�� � <br /> _ _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted _� 0 �� <br /> Date�?!.w� _ Area 8 <br /> Pit or Grout Inspectionby �] f _ 7 e--`1 <br /> Date ate Z -7� Final fnspection by DateA <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH1 -24fREV.i/851 <br /> EH 1428 <br />