Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 w <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.54.9 for sewage or No„1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.,,,, <br /> /�� r . <br /> Job Address 1— City eee������ Lot Size PM <br /> Owner's Name_6��� cess �� a Phone 3 3­0 <br /> Contractor's Name - — " cense No. Phone cl 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ J WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ET' 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 /> 2"Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> El Public ❑ Other _ t ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑-Irrigation _ -_ Approxi Dept 0-Eastern urface.Seal-Installed <br /> -.hy-- -- <br /> —Repair Work Done Gd' Type of Pump H.P. State Work.Done <br /> J_ 5 <br /> - Well Destruction ❑ Well Diameter Sealing Material (top 50'1° <br /> ~ y Depth Filler Material (Below 501. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION;❑' DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> ` 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 />` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well + i+oundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El' Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS El Depth Size Number <br /> "SUMPS *❑ Distance to nearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS ❑ <br /> E 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 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." Contractoes hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of fornia."a <br /> The applicant call or all re d inspection . Complete drawing on r erse side. <br /> Signed itle: Date: <br /> F6fr6E1PARTMENT,-VSE ONLY <br /> Application Accepted by — Pp ; DateYArea <br /> Pit or Grout Inspection byQate Final Inspection by f Datew <br /> Additional Comments: <br /> © Stk 466.6781 ❑ Lodi •36'9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ,Applicant.- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box ZM, Stk., CA 95201 <br /> _ f <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24(REV.10183) , <br /> EH 1428 <br />