Laserfiche WebLink
APPLICATION,FOR PERMIT <br /> SAN JOAQUIN LOCA' <br /> HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAhh FROM DATE ISSUED <br /> (Complete Ili Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pelr�mit 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 City•-'= of Size �; PM <br /> Owner's Name ► Address 0 Phone .3 Q <br /> Contractor's Name License No. Phone <br /> TYPE OF WELLAEUNg. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION A& SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �M DISPOSAL FLD. PROP. LINE <br /> •F <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ,F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Nt Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> #1 Domestic/Private El Gravel Pack ❑ Tracy Typelof Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> a ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> '.%Repair Work Done l? Type of Pump H.P. State Work Done e.,&�af <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material {Below 50') { - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONI❑ DESTRUCTION ❑ (No septic system permitted if public sewer is W <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 Foundation Property Line <br /> X !€ - ,r.,"'",meq ''• " <br /> LEACHING LINE ❑ No. & Length of lines tal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size # Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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."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 must call. or all required inspections. Complete drawing on reverse side. <br /> r � <br /> Signed Title: Date: "' <br /> I <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by /l/ F Date Z� Area <br /> Pit or Grout Inspection by ti 1ADate Final Inspection by Data I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 j� ❑ Tracy 835VM <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 CASH RECEIVED BY 4 DATE PERMIT"NO. <br /> INFO " <br /> 4500 <br /> + EH 13-24(REV-10/03) <br /> EH 1426 F <br />