Laserfiche WebLink
I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 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 City9&Z,-9,t Sizeyy p <br /> ,' <br /> I Owner's Nara Address Phone <br /> Contractor's Name icense No. Phone <br /> TYPE OF WELL'/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I 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 QW <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type,of Casing — Specifications <br /> ❑ Public L7 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done ! of <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONIK <br /> REPAIR/ADDITION ❑ DESTRUCTIO o septic system permitted if public sewer is <br /> a t available within 200 feet.) <br /> Installation will serve: Residence-J— Commercial_ Other <br /> Number of living units:—I— Number of bedro s-�o _ f <br /> k Character of soil to a depth of 3 feet: a� K Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El _ �o �` Method of Disp9sal <br />{ O r, 4 - Q <br /> IFI Distance to nearest: Well�� Fouu scout ndation Property Line <br /> � a <br /> I LEACHING LINE ❑ No. & Length of lines it 4F- 7�k- Total length/size <br /> l FILTER BED ❑ Distance to nearest: Well 99 Foundation � Property-Line- <br /> SEEPAGE PITS Depth __ �` Size Number <br /> SUMPS ❑ Distance to nearest: Well-1. Foundation_41-90 Property Line-'x <br /> DISPOSAL PONDS ❑ <br /> I "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 /> E 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." <br /> I' The applicant must all, II required in ctI ns. Complete drawing on reverse side. <br /> I Signed" Title: f7) 4 <br /> - Date: <br />' s ���C� FOR CEPA USE ONLY l� <br /> I Application Accepted by / ?''/f " Date r e <br /> jPit or Grout Inspection by l[ - v` DateC e� - Final Inspection by Date C <br /> Additional Comments: AV <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 CK 0 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> f'= <br /> +EH 13-24{REV. 101831 l��• �rJ/ <br /> EH 14-28 <br />