Laserfiche WebLink
APPLICATION FOR PERMIT ` 'NQ <br /> Ily SAN JOACIUIN LOCAL HEALTH DISTRICT � r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA L� <br /> Telephone (209) 466-6781 <br /> 1 PERMIT EXPIRES TYEAR 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 1 Job Address ,2 <br /> `«-�,y City Lot Size PM <br /> Owner's Name Address . litre� _ Phone/ ,5— <br /> E � _ <br /> Contractor AddresAc Licens � Pho <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. — <br /> FOUNDATION AGRICULTURE WELL OT ER^W LL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> F)Public 17 Other alta Depth of Grout Seal Type of Grout _ <br /> i I Irrigation _-Ap epth l I Eastern Surface Seal Installed by `� <br /> Repair Work bone ❑ of Pump H.P. State Work Done <br /> F <br /> Well Destructi Well Diameter Sealing Material Itop 50') <br /> gepth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTIO (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> t Installation will serve: Residence�" Commercial_ Other <br /> Number of living units: Number of bedrooms ' /Y f <br /> Character of soil to a depth of 3 feet: .4, Water table depth <br /> SEPTIC TANK: � p Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. IT) _ _ Method of Disposal <br /> 4 Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED "❑ Distance to nearest: WeltFoundation 'n4 Property Line <br /> 3 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS D 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 Doltrict. <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:owing: "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" ctions. Complete drawing on re e side. <br /> Signe Title: Date: S <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date� ' <br /> � Area / ,7 <br /> Pit or Grout Inspection by _ Date Final Inspection by Date +� d <br /> Additional Comments: <br /> ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24 a.EH 14-26 INEV.I/a 5) V_ 2/7 <br /> k <br />