Laserfiche WebLink
APPLICATIONk.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALtH DISTRICT <br /> 1601 E. HAZELT.ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Y, t <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 /> City C��"CSt Size— PM <br /> Job Address } I <br /> Owner's Name <br /> /nr�yJ�.cO /lrvG .l► <br /> Address <br /> Phone <br /> +U Phone <br /> Contractor's <br /> No._ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L3 <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR 16 OTHER 11 <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES ice-- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Xpomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> ❑ Public ❑ Other (� <br /> ----Approx.,Irrigation �gpprox., Depth Eastern Sr ce Seal Installed by CJC <br /> Type of Pump H.P. 41--" _ ;State Work Done <br /> ;-- Repair Work Done YP <br /> Well Destruction C] Well Diameter =Sealing Material Atop 50'i <br /> Depth Filler Material [Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION ❑ DESTRUCTION ❑ (Noavastile'with tem emitted if public sewer is <br /> eet,I <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type/Mfg Capacity <br /> SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ .I Property Line <br /> Distance to nearest: Well Foundation <br /> —Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> SEEPAGE PITS ❑ Depth' <br /> Size ` Number <br /> SUMPS ❑ Distance to nearest: X �Wel1 <br /> Foundation '" Property Line <br /> I. +' <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, an <br /> rules and regulations of the San Joaquin Local H#alth District "' " work for <br /> rmance of Home owner ersonlicensed in <br /> uch manneras signature <br /> become subject to workman's kman'scertify <br /> compensation lawsofCaliforn ahe Contractor's lhir gl or sub-contracting lsignlature <br /> employ Y Pe <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 /> The ap li m t call for all requlr lnspecti s. Co ete drawing on re erre side: <br /> _ .. 7 — Date: <br /> Signed <br /> –. Title: , <br /> - 4 <br /> �q. .. / FOR DEPART ENT USE ONLY yam/ <br /> ` t,(r Date V Area <br /> Application Accepted by, <br /> Pit or Grout Inspection bye <br /> Date Final,ln"spection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> ironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Env <br /> CK* RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13.24{REV.101931 <br /> EH 14-26 <br />