Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 A <br /> PERMIT EXPIRES TYEAR 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 /> rx� 30 Y ' b City 14ot Size_ I�°Q T 7 �PM <br /> 1b Address ([ <br /> III```Owner's Name , >t � ddress i��% ©$ 4) Phone <br /> Contractor v.,%Ab Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> MP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEP TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATI AGRICULTURE"WELL OTHER WELLY PITS/SUMPS. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> ❑ Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.-Approx. Depth l 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 /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION LI DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence_ Commercial_ Other <br /> f Number of living units: Number of bedrooms <br /> If Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal Z <br /> Distance to"nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i'I Depth Size Number <br /> SUMPS L-1 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 Di?;trict. <br /> t nthe performance of the work for which this permit issued, I shalt/not <br /> Home owner or licensed agent's signature certifies the followig: "I certify that in <br /> k 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 /> 4 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." <br /> t The applicant must <br /> o . <br /> call for ail required inspections. Complete drawing on reverse side. <br /> I Signed X ��- — Title: _ _ Date: <br /> USE ONLY <br /> Application Accepted by Date ^ Area <br /> r Pit or Grout Inspection by Date Final Inspection by 6�- Daapot <br /> E Additional Comments: <br /> ❑ Stk 466-6781 L1 Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 <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 REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO /rte <br /> +.EH 13-24(REV.f/H 5) _7\, (J lJ �-" Q [ C 4'~7� ( t � ! <br /> EH 14-26 J , <br />