Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> w Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> application is <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 <br /> made in compPance 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. lR ZZ L( <br /> 1 /� City A) Lot Size 6KYPM <br /> Job Address <br /> �(J Address Phone r <br /> Owner's Nam <br /> Contractor's Name �! <br /> License No. Phone <br /> TYPE OF WELL/PUMP:Y.• ;. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTAL TION SYSTEM REPAIR ❑ OTHER ❑ fes, <br /> °� _ DISPOSAL FLD, t PROP. LINE Icy t <br /> DISTANCE TO NEAREST: SEPTaC TANK �� SEWER LINES Q OTHER WELL PITS/SUMPS <br /> FOUNDATION� AGRICULTURE WELL� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ElIndustrial ❑ Open Bottom ElManteca Dia. of Well Excavation <br /> � <br /> T of Casin _S � Specifications <br /> Q�Dom ❑ <br /> estic/Private ❑ Gravel Pack ❑ Tracy y g Type of Grout k� <br /> �b` OtPublic <br /> her ❑ Delta Depth of Grout Seal <br /> El Irrigation --Approx. Depth ❑ Eastern S� ace Seal Installed by <br /> Sta <br /> Repair Work ❑ Type m <br /> of;Pup. .yAig1Y1 -_ H.P. te Work Done <br /> e <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system <br /> tem emitted if public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms �k <br /> Water table depth <br /> Character of soil to a depth of 3 feet: I <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation <br /> ' Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> + FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i, i <br /> f SEEPAGE,PITS ❑ Depth Size Number <br /> SUMPSPro a Line <br /> ❑ Distance to nearest: Well Foundation � Property <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�Jbaquin Local Health District. ssued, I shall not <br /> Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is i <br /> s <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's <br /> to orkmariisgCompensa <br /> certifies tftie'following:"I certify that in the performance of the work for which this permit is issued,1 shall employ P@ <br /> tion laws-of California." 1 <br /> The applica st call for all required ins cions. Complete wing on reverse side. <br /> I Title: Date: <br /> ! Signed ' <br /> FOR DEP TMENT USE ONLY Date Area <br /> ���� ✓ <br /> Application Accepted by <br /> '_ Date <br /> Pit or Grout Inspection by,' Date anal Inspection by <br /> e� �v h.�c Y <br /> Additional Comments: ,r Z <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385nby <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rf�✓ r <br /> r <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'N0, <br /> x INFO --- <br /> _.� .- -- gg vo l 203 $_z�- ps_�o3°s <br /> c *+-EH,13.24{REV.10/83) 4 <br /> EH 14-26 - i <br />