Laserfiche WebLink
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 <br /> ! (Complete in Triplicate) <br /> # Y <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 / R r , <br /> City Lot Size PM <br /> .. <br /> { Owner's Nam Add ess r' ` Phone 1! <br /> Contractor Address a <br /> License N Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ r WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i # i RUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER.❑ ` <br /> j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL"D. PROP. LINE <br /> FOUNDATION - AGRICULTURE WELL OTHER WELL`__! -' PITS/SUMPS <br /> INTENDED S {.,.`"-TYPE 0F;V1lELL­4 PROBLEM AREA -CONSTRUCTION SPECIFICATIONS- <br /> ❑ Industrial ❑ Open Bottom I ❑ Manteca Dia afWell'Excavation '"' <br /> Dia- of Well Casing <br /> r x❑ Domestic/Private ❑ Gravel Pack ❑ Trac + <br /> _ y Type of Casing Specifications <br /> M Public ❑ Other ' e <br /> i ( 1 Delta > Depth of Gamut Seal f Type of Grout <br /> I I lrrigation App►ox. hep h I 1 Eastern "� �5urface Sea! Installed by�"� - <br /> Repair Work Done ❑ Type of'Pump H.P. State Work pone <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:) REPAIR/ADDITION 'DESTRUCTION I I iNo septic system permitted if public sewer is <br /> I , /_ I.`,F available within 200 feet.) <br /> t Installation will-serve: Residence_ Commercial_ '6tler <br /> Number of living units: __L_ Nu'rriber of bed` o s f <br /> Character of soil to a depth of 3 feet: r Water table depth ^ <br /> SEPTIC TANK ❑ Type/Mfg ` r` Capacity No. Compartments �3 <br /> PKG. TREATMENT PLT.,❑ ;. p <br /> Method of Disposal t <br /> Distance to nearest: Well'"' ' <br /> Foundation Property Line <br /> LEACHING LINEX No. & Length of lines <br /> Total length/size Q x >� . <br /> FILTER BED ❑ Distance to nearest: WeC� Foundation s <br /> Property Line <br /> t <br /> SEEPAGE PITS 1 Depth _-�� Size_..., ,P� _� Number 2_.A <br /> SUMPS, Ll Distance to nearest: Well ___ Foundation—1,0 Property Line _ J <br /> ....."DISPOSAL PONDS­❑—� <br /> f ! 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant rttu t call for all r quired ins ions. Complete drawing on revs sid " <br /> Signed X Title: w Q <br /> _. Data: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by Date Srg <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 D 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 CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 14-241REY.FiN57 � ��/ � � <br /> EH 14-28 �/n(a/ <br />