Laserfiche WebLink
r f I <br /> I <br /> r APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-Ml <br /> 4 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 /> in compliance with San Joaquin County Ordinance No.549 or sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. \ C <br /> Job Address <br /> j0 � J City Lot Size %O A-Li 0 PM <br /> Address Phone <br /> Owner's Name <br /> �j <br /> License No. Phone <br /> 1 <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r *1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t <br /> a <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> 11 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 /> (No seTYPE OF SEPTIC WOR NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION availablelwith ne200 feett'ed if public sewer is <br /> -41 <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms m <br /> " 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 <br /> Distance to nearest: Well Foundation ProPerty Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <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 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 st call for all required i spections. Complete drawing on reverse side <br /> Signed Title: Y Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by - Date ea—!R/ <br /> Pit or Grout inspection by Date Final Inspection by ate <br /> Additional Comments: <br /> I ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 r ❑ 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 I AMOUNT DUE AMOUNT REMITTED ou CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> s + EH 1324(REV.101834 1 b- — ~� <br /> EH 1428 <br />