Laserfiche WebLink
1 <br /> t <br /> i APPLICATION FOR PERMIT �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTFr <br /> w <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or install the work <br /> cation is <br /> made in corms compliance with Sano the San Joaquin Local Health District for a Joaqu n County Ordinance No.549 for sewage or permit <br /> No. 1862 forcwell/pump and the Runes and hereinR Regulations of tlhe Sanis 'Joaquin <br /> made p <br /> Local Health District. <br /> t Siz T��l /-50F <br /> ( Cit <br /> Job Address <br /> Owner's Name <br /> r Is Phone <br /> Address License No. <br /> Phone <br /> Contractor <br /> TYPE OF ELL/PUMP-, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> E3 Industrial ❑ Open Bottom 1-1MantecaDia. of Well Excavation <br /> Type of Casing Specifications <br /> RS <br /> ❑ Domestic/Private ❑ Gravel Pack 17 Tracy Type of Grout--- <br /> M <br /> rout — <br /> [l Public L] Other Cl Delta Depth of Grout Seal "V <br /> I l Irrigation Depth Depth i I Eastern Surface Seal,Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H p State Work Done <br /> Weil Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION I 1 DESTRUCTIO (No <br /> septiAh <br /> ailable <br /> system <br /> feet.)permitted if public sewer is <br /> I-Sik Installation will serve: Residence— Commercial— Other <br /> r Number of living units: Number of bedrooms Wa <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No <br /> MeiPKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property <br /> LEACHING LINE ❑ No. & Length of lines Total length/.size <br /> 7 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i SEEPAGE PITS I i Depth Size Number <br /> I SUMPS Ll 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 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 m all r all r quire spect�nsCo-�pleterawingon reverse side. r <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> k Pit or Grout Inspection by <br /> - -�^ DateFinal Inspection by ate <br /> Additional Comments: 7 <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 /> 1 <br /> FEECIC RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24 IREV.i i R51 <br /> 4 <br /> EH 14-2a <br />