Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 <br /> City AP C Lot Size—rte AG PM <br /> Owner's Name 10M Address hone <br /> Contractor's Name f L/ F_L6 ,CM_ License No. Phone <br /> TYPE OF WELL/PUMP: 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 /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by ! <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 (1 <br /> Depth Filler Material (Below 50') �} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) Q <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Cti <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK V Type/Mfg Capacity ZaeZ:V_ _—, No. Compartments C <br /> PKG. TREATMENT PLT. ❑ p� F� Method of Disposal <br /> Distance to nearest: Well ,3 <br /> �1�0 Foundation� Property Lina <br /> V <br /> LEACHING LINE ( No. & Length of lines — Total length/size' ��� Ile <br /> FILTER BED ❑ Distance to nearest: Well�� Foundation� Property Line. .1-7- <br /> 0 <br /> SEEPAGE PITS ❑ Depth Size "Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 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 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 forP4 reuired inspections. Complete drawing on reverse side. <br /> Signed X Title: �.c�+.�-� [ Date: <br /> FOR DEPARTMENT USE ONLY ` q <br /> Application Accepted by Y r Date i Area 0 7 <br /> Pit or Grout Inspection by ate Final Inspection by `/� � Date <br /> Additional Comments: "r' � C� �e> <br /> ❑ Stk 466-6761 ❑ Lodi 369-36221 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVER BY DATEt PERMITNO. <br /> + EH 13-24 MEV.f0/a31 y'�`� �" �� jo-tN~TY gC f�/3 fRa - <br /> EH 1426 <br />