Laserfiche WebLink
,S �1 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> �00�` Telephone (209) 466-6781 <br /> �P PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> At4�_ (Complete in Triplicate) <br /> A�lfca;j�N"s hfI�Xy 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. /� ,rf <br /> Job Address <br /> ,2/ td. I�UA2T,,/Z 6✓A Y' City -Alee-kf Lot Size PM <br /> Owner's Name <br /> .l�0 Address Z/ 41 tfl.,�e.` Phone,f �it1i-. Address 2(p�s C fj/a License No. -2­7-�v,j <br /> Phone t� '' '1� <br /> Contractor � <br /> TYPE OF WELL/PUMP: NEW WELL>r WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1>J go''I � di 11's <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 /> El Industrial C3 Open Bottom U Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack U Tracy Type of Casing_ Specifications <br /> FI Public n Other [1 Delta Depth of Grout Seal Type of Grout ' <br /> I I Irrigation _._Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done U Type of Pump _ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Ll 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, 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." SAN JOAQUlN LOCAL HEALTH DISTRICT <br /> The applica call for all required 'ns ct' ns. Complete drawing on rever�se/�siJde. ENVIRONMENTAL HEALTH UI ISI �QNfl <br /> Signed Title: ,! 'C df 'i• S,r���l�i� d <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _—.._ Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <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'NO. <br /> INFO CASH <br /> 4 EH 13-24(REV.r/x 51 <br /> EH 14-26 <br />