Laserfiche WebLink
APPLICATION FOR ?ERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> r > (1 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 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 _ Y <br /> City of Size PM <br /> Owner's !Name + Address <br /> Phone _ <br /> Contractor. ( Address / <br /> TYPE OF WELL/PUMP: `"7aicense No.__. _Phone <br /> NEW WELL -! WELL REPLACEMENT ❑ DESTRUCTION L I <br /> PUMP INSTALLATION ! SYSTEM REPAIR X OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES <br /> DISPOSAL FLD. <br /> FOUNDATION PROP. LINE <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> Industrial ❑ Open Bottom 11 Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> �pomesticlPrivate El Gravel Pack 17 TracyLl <br /> y Type of Casing Specifications <br /> I7 Other CI Delta Depth of Grout Seal <br /> F_1 Irrigation Grout-__- <br /> --Approx. Depth F1 Eastern Type of Grout_ <br /> Surfa Seal Installed by <br /> Repair Work Done N Type of Pump r — __ <br /> H.P. State Work Done <br /> Well Destruction Ci Well Diameter <br /> - — Sealing Material {top 50'} <br /> Depth <br /> Filler Material [Below 50') <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION I 1 DESTRUCTION i iNo septic system permitted if publicsewer is <br /> Commercial� Other <br /> Installation will serve: Residence available within 200 feet.) <br /> , _ <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. 171 No.No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED CI Distance to nearest: WeIITotal length/size <br /> Foundation Property Line <br /> SEEPAGE PITS 17 Depth <br /> Size_ _ Number <br /> SUMPS 11 Distance to nearest: Well <br /> — Foundation Property Line <br /> DISPOSAL PONDS Ll <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 <br /> tion laws of California." p p y persons subject to workman's compensa- <br /> tion <br /> a nt mus call for all req d inspe ons. Coryl�lete drawing on revere side. <br /> Signed X_ �� <br /> - � Title: ' � <br /> ! Date: „ ;z <br /> OR DEPARTMENT USE ONLY <br /> Ap .lication Accepted by � \ <br /> -.-- �-- �� <br /> - - i <br /> Pit or Grout Inspection by Date Area. <br /> 3 <br /> DateFinal Inspection by_ - �� ��( <br /> Additional Comments: Date F --:l��k <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 /> FEE AMOUNT DUE CK <br /> INFO AMOUNT REMITTED RECEIVED BY CASH DATE PERMIT NO. <br /> + EH 13-24(REV-i;6 5) —) <br />