Laserfiche WebLink
- APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA b <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED j <br /> (Complete in Triplicate) <br /> t and/or install the work <br /> .This <br /> Application <br /> Icom compliance with San Joaqthe uin n Couan nty ordinance uin lHealth District for a Ncation is <br /> o.549 for sewage or permit <br /> No. 1862 for cwell/pump and the Rules and IR Regulations of the San l Joaquin <br /> ma P <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address <br /> Address Phone <br /> Owner's Name <br /> Addres License No: Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK = �- —'" SEWER LINES .,DIS FLD. PROP, LINE <br /> FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDER USE t TYPE OF WELL PROBLEM AREA C RUCTION SPECIFICATIONS Dia. of Well Casing <br /> Cl Industrial ❑ Open Bottom 'Cl Monte Dia. of Well Excavation <br /> racy Type of Casing Specifications <br /> Ci Domestic/Private ❑ Gravel Pack } Type of Grout -~ <br /> 1-1 Public ❑ Ot ❑ Deltas Depth o1 Grout Seal <br /> Approx. Depth I ! Eastern ,r Surface Seal Installed by k <br /> 11 Irrigation r State Work Done — <br /> Repair Work Done ElType of Pump H.P. <br /> Sealing Material (top 50',1 I ki <br /> Well Destruction ❑ Well Diameter 9 V" <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCT <br /> IO avaiiabpeNo lwithin 200 feetc system .) if public sewer is <br /> Installation will serve: Residence Commercial— Other ' <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth.of 3 feet: <br /> Type/ Capacity No. Compartments <br /> ❑ <br /> SEPTIC TANK _ Typ Method of Disposal <br /> PKG, TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation I Property Line <br /> LEACHING LINE 0 No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 4 <br /> SEEPAGE PITS l1 Depth . Size Number <br /> I SUMPS L-1 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, 1 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 /> I tion laws o C lifornia." <br /> 1! t f <br /> The appli t u� 11 for all re a in ctions. Complete drawing on rev rse side. �- <br /> 1 Title: Date: <br /> Signed X , <br /> D T USE ONLY i^ <br /> Date d Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date -nal Inspection byDa <br /> u�/�� �- te <br /> I Additional Comments: <br /> ccs re U 7— 3 7 <br /> ❑ Stk 466-6781 11 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trelt 835.6385 1 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ( <br /> FEECK RECEIVED BY DATE PERMIT•NO. <br /> INF OUNT DUE AMOUNT REMITTED CASH <br /> —27 <br /> ♦ EH 13-2411/n 5) <br /> I, EH 1429 <br />