Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 4664/81 <br /> 4 PERMIT EXPIRES 1 YEAR FROM-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 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. r <br /> Job Address / City Lot Size PM <br /> Owner's Name Address Phone <br /> k Contractor's Name r_aracense No. Phone t/ / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ s <br /> PUMP INSTALLATION ❑ 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 <br /> ❑ Industrial ❑ Open Bottom ❑ MartecaDia. of Well Excavation Dia. of Well Casing <br /> © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 0 Public © Other O. Della. Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Easilern 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 r <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.L. <br /> Installation will serve: Residence_ Commercial Other <br /> NumberofAvOg units: Number(of bedroom <br /> Character Wsoif to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg -— A capacity <br /> •_'p. Compartments <br /> i <br /> PKG. TREATMENT PLT.❑ 'Method of Disposal <br /> i Distance to nearest: Wdl Foundation Property Line <br /> J <br /> LEACHING LINE ❑ No. &Length of lines z <br /> FILTER BED Distance to nearest: 1Afp11 Foundation &F Property Line <br /> SEEPAGE PITS ❑ Depth SiW Number <br /> SUMPS ❑ Distance to nearest: WWI 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 folowing: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject b workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance ofifee work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> f The applicant must rAll for all requir inspections7Ce drawing on re rse side. <br /> Signed Tide: % Az ' Date: <br /> h FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> ` Pk or Grout Inspection by Final Inspection by Cti ' Date L' <br /> Additional mments: 2� <br /> ❑ Stk 4W47,8,1 ❑ Lodi 369-3621 ❑ Me.tlece82,f7104 ❑ Tracy 835-6385 <br /> Applicant- Retur"t pll copies to: Environmental Health P airs it/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> 41 _q0 <br /> 1-0,4q 17y <br /> INFO FEE AMOUNT DUE AMOUNT R�tITTED CASH RECEIVED BY DATE, PERMIT''NO. <br /> eA' r- I I I r , ­2 e2 r _eyl /1 <br />