Laserfiche WebLink
APPLICATION FOR PERMIT �L' r 64-Ot (&I, <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 />t andYor install the work <br />. This <br />cation is <br />madecin ion <br />compl compliance with SanoJoaqu nthe SanCou JoaQty Ordinance Nuin Local o. 549 for sewage or h District for a permit <br />1862 for cwellipump and the Rules and IRegulations of the Sans Joaquin <br />Local Health District.. /I /I1— I City Lot Size PM <br />Job Address V170 <br />Phone <br />Owner's Name '!� <br />� � <br />PERMIT'NO. <br />INFO { A <br />.erase Nc� % Phone <br />Contractor <br />TYPE OF WELL/PUMP: <br />ss <br />NEW WELL ❑ <br />WELL REPLACEMENT ❑ DESTRUCTIO ❑ <br />POMP INSTALLATION ❑ <br />SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: <br />SEPTIC TANK <br />SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION <br />AGRICULTURE WELL OTHER WELL PITSISUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Ll Industrial <br />LJ ;Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing <br />[2 Domestic/ Private <br />❑ Gravel Pack ❑ Tracy <br />Type of Casing Specifications <br />FI Public <br />F] Other ❑ Delta Depth of Grout Seal Type of Grout - <br />I I Irrigation <br />-_ Approx. Depth l 1 Eastern Surface Seal Installed by - <br />Repair Work Done ❑ <br />Type of Pump <br />H.P. State Work Done _ <br />Well Destruction ❑ <br />Well Diameter <br />Sealing Material (top 50'1 - <br />Depth <br />Filler Material (Below 501 <br />TYPE OF SEPTIC WORK:. <br />NEW INSTALLATION l 1 <br />REPAIRIADDITION l l DESTRUCTION l I (No septic system permitted if public sewer is <br />available within 200 feet.I <br />Installation will serve: <br />Residence Commercial <br />— Other <br />Number of living units: <br />Number of bedrooms <br />_ ..,.-��---- <br />Character of soil to a depth <br />of 3 feet: <br />Water table depth <br />SEPTIC TANK <br />0 Type/Mfg t <br />Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />❑ <br />K T <br />w Method ofi?P S <br />li Distance to nearest: <br />Weil Foundation ,Property Line �/ <br />` <br />LEACHING LINE <br />❑ No. & Length of lines <br />❑ Distance to <br />�� Total length/size /� <br />Well Foundation _�_ Property Line 1 <br />1 <br />FILTER BED <br />nearest: <br />SEEPAGE PITS <br />SUMPS <br />I 1 Depth <br />❑ Distance to nearest:: <br />Size umber <br />Well Foundation -Num or <br />Property Line <br />J <br />DISPOSAL PONDS <br />❑ <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 />I <br />The applicant t cal r al , quired i coons: CompI a drawing on xelbrsa side. <br />Signed X Title: Date: <br />FOR DEPARTMENT USE ONLY <br />to '� Date - la' Area (� <br />Application Accepted by - - <br />�!l <br />Pit or Grout Inspection by Date Final Inspection by Date <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 />+. EH 13-24 IREV. i i H 5 <br />EH 14-26 <br />FSE AMOUNT DUE AMOUNT REMITTED ASH <br />RECEIVED BY <br />ATE <br />PERMIT'NO. <br />INFO { A <br />