Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or <br /> all the work <br /> n describe . This <br /> cation is <br /> madeint <br /> ntcompliance with SanoJoaqu nthe San County Ordinance No.549 for sewage or Joaq uin Local Health District for a permit <br /> 1662 for cwell/pump atnd the Rules and(Regulations of the San'Joaquin <br /> Local Health District. T g�0 <br /> _ City Adjoad Lot Size PM <br /> Job Address <br /> Owner's Name <br /> (Add ess Phone <br /> KQ Z License No.g�. Phone <br /> Contractor Address < <br /> TYPE OF WELL/PUMP: EW WELL VL WELL REPLACEM T DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> PROP. LINE QN <br /> DISTANCE TO NEAREST: SEPTIC TANK � _ SEWER LINES DISPOSAL FLD. ddb <br /> FOUNDATION _ a -'--- AGRICULTURE WELL � OTHER WELL r PITS/SUMPS ZZ-1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open-Bottom ,k ❑..Manteca Dila.of Well.Excavation Dia. of Well Casing <br /> ' Domestic/Private )7 Gravel Pack ❑ Tracy Type of Casing <br /> 11 o Specifications <br /> i <br /> M Public 11 Other 17 Delta Depth of Grout Seal r Type of Grout <br /> s� fA '"Surface Seal installed by ®' '� <br /> I'I Irrigation pr VW- pProx. Depth l I Eastern <br /> Repair Work Done LJType of Pump _�'u _ H.P. —� State Work Done— I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') (�v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION iJ DESTRUCTION I I (No septic system permitted if public sewer is <br /> a available within 200 feet.! <br /> Installation will serve: Residence— Commercial Othe= <br /> a <br /> Number of living units: !Number of bedrooms <br /> Character of soil to a depth of 3 feet: fi Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 'Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ x Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> IN <br />' LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation„. Property Line " <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> - DISPOSAL PONDS ❑ <br /> 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"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,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must c I for all wired inspections. m let ing on reverse side. <br /> Signed X ' Title- Date: r <br /> OR DEPART'ME USE ONLY <br /> f Application Accepted by Date -��~ � _ Area_ t-10" - — <br /> Pit or Grout Inspection by Date � Final Inspection by10A <br /> Additional Comments: <br /> ❑ Stk 466-6781 E3 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 /> F " <br /> �=f. <br /> FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> i ♦.EH 1321(REV.t i e 51 D �l`� " Q ✓ <br /> EH 14-2a <br /> l - <br />