Laserfiche WebLink
1 APPLICATION FOR PERMIT j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT l <br /> 1601 E. 1-IAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> I <br /> (Complete in Triplicate) I <br /> _ 1 <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 /> I i <br /> Job Address' �+ City Lot Sil e <br /> f i 4 /tt <br /> Owner's Name Pa A J Address C J / Phone (J <br /> Contractor dress -4 <br /> 6n . N/ �� Phone OC <br /> TYPE OF WEL4/ - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q� <br /> [I Domestic/Private ❑ Gravel hack ❑ Tracy Type of Casing Specifications v <br /> F] Public 1-1 Other C-1 Delta Depth of Grout Seal C Type of Grout <br /> --- <br /> I I Irrigation Approx. Depth 1-1 Eastern— -- Surface Seal Installed by _ C <br /> Repair Work Done ❑ Type of Pump H.P. State Work Donej_ <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 + <br /> Depth Filler Material (Belo 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI N l 1 REPAIR/ADDITION l DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other I <br /> Number of living units:''-Number of bedr s <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments <br /> PKG. TREATMENT PLT. L1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED 1711 Distance to nearest: Well Foundation iJ�_.-- Property Line <br /> SEEPAGE PITS l I Depth r u ber I J <br /> UMP Distance to nearest: __.. Well 1012 Foundation_ Property Lige <br /> ISD PDSAL 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. II <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 California." <br /> The applicant mu al r aEl r d inspectioyrs. 96mptele drawing on reverse side. <br /> Signed X Title: Date: <br /> I <br /> FOR DEPARTMENT USE ONLYot <br /> + <br /> Application Accepted by Date _4011 Area <br /> r <br /> a <br /> Pit or Grout inspection by Date Final Inspection b Dat@/ <br /> 'I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 L] 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 /> CKO <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH13-24 TREY.1/451 <br /> EH 14-26 <br /> 1 <br />