Laserfiche WebLink
APPLICATION FOR PERMIT <br /> Sr, JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR..FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Heahtt District for a permit to construct end/or install the work herein described. TMs application is <br /> made in compliance with Sen Joaquin County Ordinance,No,,649 for sewage or No. 1862 for'well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> rLot 5 1R f +PM <br /> Job Address C'ry <br /> Owner's Hama ddress. �'t <br /> Contracloi � Addre"S' "i'r License No. Phony ~ <br /> TYPE.OF WELL/PUMP: NEW WELL O - WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION O 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 ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Speciftations <br /> 11 Public ❑ Other ❑ 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 ❑ Type of Pump __moi H.P. State Work Done_ A' <br /> Well Destruction O Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 601 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION T 1 REPAIR/ADDITION I I DESTRUCTION t l (No septic system permitted if public sewer is <br /> i 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 /> 0. �J <br /> SEPTIC TANK ❑ Type/Mfg Capaci No,tCoifts <br /> PKG. TREATMENT PLT.❑ .. mpartrtreMethod of Disposal <br /> " Distance to nearest: Well Foundation Property Line ' <br /> -LEACHING LINE ❑. No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: V1/e ` Foundation Property line j <br /> -5 AGE PITS 11 Depth - .-� <br /> e ? Number <br /> 11 Distance to nearest: WI '' Foundatiorr✓ 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 pwner 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." / <br /> The applic tnuy clll for-til requ�ed inspections.JComdlete drawin9`on reverse side. <br /> J( f� ! �" <br /> r 11 ` <br /> Signed X r ' t � T1tle Date 1 �' f <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted Data, Area <br /> Pit), Grout Ins c ' by f 1 f~Date�L-,c i, i Final Inspection bw�1' ,�. ��� '/f'�1:' Datey, f r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23 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 a RECEIVED By DATE PERMIT'NO. kA <br /> INFO CASH <br /> ..EH /a 1121(REV.1/ea) � ' /.S-�, 87 ^�7 <br /> EH 11-2E <br /> '.rte j- •� y-'717, <br />