Laserfiche WebLink
R- APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209)'466-6781 <br /> I 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.- <br /> Job Address S~ 4s� , Qom{, 4;6 'City ; Lot Size PM <br /> Owner's Name - Address - Phone <br /> r <br /> Contractor <br /> 4� Address License Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES L FLD. PROP. LINE <br /> FOUNDATION AGRICULTU OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P REA CONSTRUCTION SPECIFICATIONS <br /> LEIDomestic/ <br /> dustrial ❑ Open Bo ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Privateavel Pack ❑ Tracy Type of Casing I Specifications <br /> ublic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> r <br /> D Irrigation <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by i <br /> �. Repair Work Done 13 Type of Purrlp--- -H-.?7 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material '} <br /> .{top 50 <br /> Depth ' Filler Material(Below 501 <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION>QNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence' Commercial Other. --, <br /> Number of living units: I Number of bedrooms aj <br /> Character of soil to a depth of 3 feet: r�' * : ! Water table depth <br /> SEPTIC TANK ❑ Type/Mfg y= ' '•Capacity I No. Compartments <br /> PKG. TREATMENT PLT. ❑ k J 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 /> r SEEPAGE PITS ❑ bepth w Size Number <br /> SUMPS ❑_. Distance to nearest: Well Foundation Property Line <br /> q DISPOSAL PONDS ... ;:❑ j <br /> I hereby certify that I havelprepared 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 terrify 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.'r Contractors 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." <br /> The applicant 7t call for all required inspects:Complete drawing on reverse side. <br /> I Signed s Title: " <br /> Date: <br /> FOR,DEPARTMENTUSE-ONLY.__—L-. <br /> Application Accepted by Date -�� Area 3 <br /> Pit or Grout Inspection by Date Final Inspection bye Dat <br /> Additional"Comments: i - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT.REMITTED CK id:z <br /> D BY DATE PERMIT NO. <br /> + EH 13-24(REV.k/a51 3�� ry,_ - <br /> EH 1428 / / <br />