Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 4'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> l <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. t <br /> Job Address Zf)_QCity Lot Size PM <br /> Owner's Nani Address Phone <br /> Contract r Address s /w r License No 7 Z�' Phone �D —.1!vS <br /> TYPE OF WELL/PUMP: NEW WELL L WELL REPLACEMENT ❑ DESTRUCTION ❑ \ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r <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 <br /> ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack- - ❑ Tracy - Type of Casing Specifications <br /> - Y <br /> (1 PublicC1 Other ❑ Delta Depth of Grout Seal Type of Grout _, r <br /> 4. ;. <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done `.❑ Type of Pump H.P. State Work Done <br /> k <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 64r REPAIR/ADDITION 1.1 DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number'of liv1 oing units: A_ Number edroo <br /> - <br /> Character of soil to a depth of 3 feet: Water table depth >� <br /> SEPTIC TANK-' I [�thType/Mfg 1 Capacit 06 No. Compartments <br /> ~PKG. TREATMENT PLT. ❑ [ r Method of Disposal <br /> C_ Distance•to nearest: Well Foundation 10 Property Line [ <br /> LEACHING LINE-, No. & Length of lines Q Total•_length/size K UA,"A - , <br /> , r <br /> FILTER BED ❑ Distance to nearest: Well.N50 Foundation _Its r Property Line <br /> SEEPAGE PITS i'1 DepthSi <br /> r� ze— j Number �- <br /> 2 ' <br /> SUMPS Y L1 Disiance-to-nearest:�`Vilell � t Foundatior .� Property Line ; <br /> DISPOSAL PONDS El <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: "1 certify that,in the performance of the work-for which this permit is,issued,.l shall not <br /> I employ any person iri 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'tftis-paimit'i's issued,I shall empl5y persons subject to workman's compensate +� <br /> i <br /> tion laws of California." <br /> The applicant nikKcall fora qu' d inspections. Complete drawing on revers side. <br /> Signed n Title: �. Dale: <br /> FOR DEPARTMENT USE,ONLY"; <br /> Application iAccepte by Date f 2— ✓' Area <br /> Pit or Grout Inspection by Date Final Inspection by Dat <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 <br /> INFO AMOUNT DUE I AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> ♦ EH13-24(REV.i/n 5) <br /> EH 14-26 / f <br /> 9 <br />