Laserfiche WebLink
4k <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT d <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA ' <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) Y• <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 Sart Joaquin <br /> Local Health District. ' <br /> f a 86= a - <br /> Job Address City Lot Size PM <br /> '7� J <br /> Owner's-Name -11&-Y.► Address Phone <br /> �� <br /> •• II o i <br /> Cpntract ��r Address � ��( 71v 7 &td, License No_3 Z$ Z Z-(e Phone CO <br /> TYPE,OF WELL/P.UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'A� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. " � State Work Done ^ <br /> Well Destfuction> Y❑!!'Well-DiameterSealing Material_ftop,;50) * Iv <br /> --Depth Filler_.Material.(Below-50') —�-� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ R AI ADDITION P`DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> I s available within 200 feet.h <br /> Installation will serve: Residence ✓ Commercial—Other— <br /> Number <br /> Other Number of living units: Number of blr oms <br /> Character of soil to a depth of 3 feet: /� - ' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg i 1 �"/•: t Capacity No4�Com,p�rtrrments <br /> PKG. TREATME LT. ❑ I f _ i �- Method of-Disposal <br /> f ) .a <br /> S <br /> Distance to nearest: i Well�^Foundation Property-Line— <br /> LEACHING LINE CYNo. & Length of-lines ` qn Total length/size d <br /> i <br /> FILTER BED ❑ Distance to neo st . "Well L!5_0" Foundation ,C(L t"'Property Line :5'- <br /> �� ` <br /> SEEPAGE PITS Depth Size 419 Number <br /> SUMPS ❑ Distance to nearest: Well 106' Foundation 10 � Property Line_.S <br /> I <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 /> r„nw Home owner or licensed agent's signature certifies the following: 1 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 st call for quired inspections. Complete drawing on reverse side. <br /> �.P dg� <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by &6Date Area <br /> Pit or Grout Inspection by 1 11 Date Final Inspection by Date <br /> Additional Comments: <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> INFO CASH <br /> + EH13-241REV.1/a5) <br /> EH 14 28 <br />