Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 /> 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 ' y "^"t City Lot Size �v ° �'— PM <br /> Owner's Name ' f r Address /00 / I 'G^ ' `� � • Phone <br /> Contractor 0� �r ddress lae�fS2 <V License No,7` -S��f Phone <br /> TYPE OF WELL/PUMP: NEW WELL 91�-- 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 PITS/SUMPS <br /> INTENDED USE TYPE" OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r. <br /> CJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> j omestic/Private ravel Pack ❑ Tracy Type of Casing S'C�r'7Specifications <br /> F] Public Cl Other 17 Delta Depth of Grout Seal �� w Type of Grout <br /> i I Irrigation —_Approx. Depth I 1 E tern !Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump `' H.P. /;E? Statue`Work one_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AITION I I DESTRUCTION I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms _ <br /> 1 Character of soil to a depth of 3 feet: Water table depth <br /> r <br /> SEPTIC TANK ❑ Type/Mfg )Capa ity No. CompartmentsPKG. TREATMENT PLT. C1Method of DisposalDistance to nearest: Well Fion Property Line <br /> LEACHING LINE ❑ No. & Length of lines Z Total length/size ` <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size NumberCN <br /> SUMPS ❑ 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 /> 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 shalt 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 compensa- <br /> tion laws of California." <br /> The applican us t c II for all req ui din clions. Complete drawing on reverse side. <br /> 1 r r; <br /> Signed X Title: © pate: <br /> 1 � <br /> OENT USE ONLY ;k <br /> Application Accepted by Date ^ Area <br /> Pit or ro Inspection by Date r` Final Inspection by=��'f// 4 Date n <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> INFO FEE AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PE MIT'NO. <br /> + EH 13-21(REV.t i rs 5) /O �--3 {�/aO <br /> EH 14-29 6 V <br />