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 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t to <br /> t and/or install the work <br /> n described. This <br /> cation is <br /> madlecin'compliance wetebyr th Sano <br /> oJoaquin County Ordinance Nto.549 for sewage o(the San Joaquin Local Healh District for a No. 1862 for cwell//pump and the Rules and'R Regulations of the San Joaquin <br /> Local Health District. . <br /> Gy Cj•a�• City Lot Size PM <br /> ,lob Address - d} <br /> ) +�Tc� <br /> Owner's Name � �^^ Address Phone <br /> Contractor <br /> n Address `^ License No � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL PUTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> Type of CasingSpecifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp <br /> {'l Public <br /> Ll Other ❑ Delta Depth of Grout Seal Type of Grout--- <br /> I <br /> rout -I I Irrigation —.-Approx. Depth 1 I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Wbrk Done _ V <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 t� <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 RCPAIR/ADDITION DESTRUCTION I I iNailabptic systemithin rented if public sewer is <br /> avle Installation will serve: Residence X Commercial_ Otherr <br /> Number of living units: Number of bedrooms f '� <br /> Character of soil to a depth of 3"feet + Water table depth <br /> Type/Mfg _� �-�'• - - sCapacityQT No. Compartments <br /> SEPTIC TANK <br /> ElMethod of Disposal <br /> PKG. TREATMENT PLT. f <br /> Distance to nearest: Well Foundation Zd9 - Property Line p <br /> 4 - <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well r 4oundation Property Line <br /> SEEPAGE PITS t 1 Depth Size " """" Number <br /> SUMPS Ll Distance to nearest:t{� pollFoundation 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 Di%trict. <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, l shall employ persons subject to workman's compensa- <br /> tion laws of Calif ia." <br /> ons. <br /> The applicant call for all required s iomplete drawing on arse side <br /> Signed �`'` Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> App i tion Accepted by Date Area <br /> Date Final Inspection by Date a <br /> Pit or Grout 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 2004, Stk., CA 95201 <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. \�• <br /> INFO l �j <br /> r.EH 13-24(REV,t/H 5) -7 'l (l�� <br /> EH 14-2e <br />