Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT J <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address CJS ivision Name �Fif7L <br /> Owner's Name.- �j�S Address <br /> Contractor's Name �icense No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT E] DESTRUCTION <br /> PUMP INSTALLATION 7� SYSTEM REPAIR El OTHER E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial E]Open Bottom E]Manteca Dia, of Well Excavation <br /> Domestic/Private (�Gravel Pack [� Tracy Dia. of Well Casing <br /> 17, ublic F-1 0ther E]Delta <br /> U Irrigation Approx. E] Eastern Type of Casing <br /> Depth Specifications <br /> O Cathodic Protection p Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done [ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing MateriAl (top 501) <br /> Depth Filler Material (Below 50') <br /> GO <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION [J (No septic tank or seepage pit permitted if public sewer is <br /> I <br /> Installation will serve: Residence _ Commercial _ Other available within 200 feet.) <br /> —Number of living units: Number of bedrooms - Lot size <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Ej Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION 11 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED C) Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Cj Depth Size Number <br /> SUMPS LJ 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 <br /> ordinances, state laws, and 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 <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California. <br /> The applicant st call for r qu'r i spec ns. Complete dr ing on r rse s' e. <br /> Signed X T' le: Date: <br /> URJI@1PARTRE'WWt ONLY <br /> Application Accepted by _ Area - Stk 466-6781 <br /> Additional Comments: A E3 Lodi 369-3621 <br /> Pit or Grout Inspection ' A I DateManteca 823-7104 <br /> Final Inspection by CL Date Tracy 835-6385 <br /> 11 " <br /> Applicant - Return all copies to: Envnmental Health Permit/Services 160 E. 1 on Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> L <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />