Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT OD 1L <br /> r;'> T U <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA CYC <br /> Telephone (209) 466-6781 w C L <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUEDW.w <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health <br /> District for a permit to construct and/or install the wor�in ddi'mibed� is application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rut lations�_of the San Joaquin <br /> Local Health District. <br /> C� City Lot Size PM <br /> Job Address <br /> t ddress Phone <br /> Owner's Name _ `` <br /> d I <br /> Contract <br /> Address icense No <br /> Phone <br /> Add _ <br /> TYPE OF WELL/PUMP: NEW WELL El _,..WELL-REPLACEMENT LJDESTRUCTION 11 i <br /> PUMP INSTALLATION ❑ _ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Specifications <br /> Pomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> ri Public (7 Other n Delta Depth of Grout Seal <br /> l I Irrigation —.,Approx.-Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done V Type of Pump H.P­tZ,,,-0 State Work Done <br /> ly <br /> Well Destruction © Well Diameter Sealing Material (top 501 <br /> i <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I k (Nailseptic system permfeatstped if public sewer is <br /> i <br /> ableo <br /> ithin <br /> Installation will serve: Residence, Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: f <br /> ! x_ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ # Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 1-1Distanceto nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Siie. _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ `" - fi_A L" f <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 must c Il or all require inspections. Complete drawing on r verse side. <br /> Title:. Date: <br /> Signed _ - -� - <br /> `: F. ti EPARTfNENT USE ONLY `"�---- <br /> : t <br /> [ Application Accepted by <br /> Dace ✓ � Area <br /> I Pit or Grout Inspection by Date Final Inspection /'— Date� — <br /> p Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ID 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 /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED,r C', H RECEL;K IFIVED BY DATE PERMIT NO. <br /> i INFO ems[ ^] <br /> + EH 13-24(REV.I/H 5) <br /> EH 14-28 .. <br />