Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZFLTON 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 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 <br /> �C1ty Lot Size <br /> Owner's Name ,f ,/ •� �,f r <br /> s.- '-.-Phone <br /> Contractor's,Name �� N j <br /> cense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> (?UMP INSTALLATION",', 1 <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK BO 1A--SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _` 7e OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> ❑� Ind 'a! pen Bottom ❑ Manteca Dia. of Well ExcavatioN—/.,—,D,a �/ <br /> xd'[�omestic/Private ❑ Gravel Pack El Tracy T . of Well Casing <br /> ❑ Public f Type of Casing ecifications �� <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation pe of ut <br /> _ Approx. Depth. } ❑ Ea tern Surface Seal InstalledRepair Work Done ❑ Type of Pump yp Welf Destruction ❑ Well Diameter i Done <br /> Sealing Material{top 50') } <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: ANEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ) <br /> f <br /> Installation will serve: Residence_ Commercial available within 200 feet.) <br /> — Other <br /> Number of living units: Number of bedrooms " <br /> Character of soil to a depth of 3 feet: Y <br /> SE PTIC TANK Water table depth <br /> ❑ Type/Mfp Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> =.w Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ DiTotal length/size <br /> Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size °'�" <br /> SUMPS Number <br /> ❑ 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 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 /> The applicant must call for all required inspections. Complete drawing on reverse side. 4 <br /> Signed 02, <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY �- <br /> Appl!cation Accepted by / 6 <br /> Date Area <br /> PR or ro Inspection by ate Final Inspection by <br /> 'e-C!' <br /> Additional Comments: Z111kt <br /> ❑ Stk 466-6781 0 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED 8Y DATE PER�MIIT'NO. <br /> Err 14-26 rF1Ev.10/e41 1 �SC`� �` Q—y7;1 <br /> EM 16-26 <br />