Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 comiWance 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 ! re n.rj'I City Lot Size PM <br /> Owner's Name 40 Address pt <br /> Phone <br /> I <br /> Contractor 4 G(' Address License No.��_Phone� -t4 _T <br /> t <br /> TYPE OF WEqpLL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION t❑_ SYSTEM REPAfR EI OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ,. INTENDED USE - TYPE OF WELL 9ROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industriall -❑ Open Bottom' ❑ Manteca Dia. of Well Excavation Dia, of Well Casing v <br /> ❑ Domestic/Private ❑ Gravel,Pack ❑ Tracy Type of Casing SpecificIG <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type oft -—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> 1YWel! Destruction. ❑ Well Diameter Sealing Material (top 50')Depth Filler Material (Below 50')TYPE-OF SEPTIC-WORK:•NEW-INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permiavailable within 200 feetInstallation will serve: Residence�Commercial_ Other <br /> .II.Number of living units:� Number of bedroof�1 s�II� jCharacter oij;5oil to a depth of 3 feet: Str.G1table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' Method of Disposa <br /> Distance.to nearest: Well . Foundation Property Line ' <br /> LEACHING LINE ❑ lyo. & Length:'of'7iries_ 1 a. Total length/size �G <br /> FILTER BED ' lDistance to nearest: Well_.�. _ Foundationr Property Line <br /> SEEPAGE PITS ❑ Depth -`° Size ~` Number <br /> SUMPS �II. LJ 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:` LL _ <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'pe�son 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 call for all re iced inspections. Complete drawing on reverse side. <br /> •�l <br /> Signed Title: <br /> Date: <br /> ti FOR DEPARTMENT USE ONLY <br /> Application Accepted by V411 Date Area. , <br /> Pit or Grout Inlpection by Date k � Final Inspection by_ Date- <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 L3 Tracy $35-6385 <br /> Applicant- Refurn all copies to: Environmental Health Permit/Services 1601 E.Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IiiFEE AMOUNT DUE AMOUNT REMITTED - CK RECEIVED BY DATE PERMIT"N0. <br /> ICASH <br /> i <br /> +EH 1324{REV.i/g5) /J - •/ <br /> EH 1426 <br /> f <br />