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 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ,ThFis <br /> /or install the work <br /> n descr <br /> made in o m Mance with San Joaquin County ordinanHealth ce No.District49 for sewage or't to construct No. 1862 for weli/dpump and the Rules and(Rcation is <br /> egulations of the San'Joaquin <br /> made in compliance <br /> Local Health District. t ) <br /> City <br /> S ! ( j4w iT�LKSize� . int r - PM <br /> Job Address _ -7 071, <br /> Owner's Name r <br /> /1 SIV Address Phone <br /> Cf `���.�,r � License No. Z � � Phone <br /> Contractor's Na <br /> TYPE OF WELL/PUMP: NEW WELL �� WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION <br /> DISTANCE TO NEAREST: SEPTIC TANK ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Type of Casing` - <br /> omesticlPrivate ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> ❑ Public ❑ Other El Delta <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> H P ' <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewJ1s '-,, <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ElType/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines pros Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property <br /> Size Number <br /> ❑ Depth <br /> SEEPAGE PITS <br /> SUMPS ❑ Distance to nearest: Well Property Line Foundation _ <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, stats laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agents 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: "1 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 must call for all required inspections. Complete drawing on reverse side. �+ �ZS ' <br /> � .�. Title: 1:1111 ~�' Date <br /> Signed X S4, <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Pito o t l pection byt�� <br /> Date Final-Inspection by_ Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 36&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 C RECEIVED BY DATE <br /> PERMIT"N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> EH 13-24 tnra3l °` ' 3 ``' <br /> rJS` I� <br />