Laserfiche WebLink
j APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA }Z C E V E D <br />V W Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED <br />(Complete in Triplicate) ` .ENv` ME{JTAt H�AL�H <br />RQN <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d�tJ;Jion is <br />made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ryles and RegGI`gtTor►s te San Joaquin <br />Local Health District. <br />r �r <br />�J ,r of Size ► PM <br />Job Address 1. , <br />Owner's Name IZ Address - Phone <br />939-2130-2 <br />Contractor s mo, �-Address License No�7 ��� Phone <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ "r <br />OTHER L1 <br />f <br />PUMP INSTALLATION ❑ SYSTEM REPAIR I'$ } <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.- PROP. LINE 1 <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS :-- r „ <br />INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br />❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />pomestic/Private ❑ Gravel. Pack [I Tracy Type of Casing Specifications v <br />❑ Public ❑ Othsr ❑'Delta % IDepth of Grout Seal Type of Grout <br />❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by - 1 <br />Repair Work Done K Type of Pump 91 H. P. State Work Done <br />Well Destruction Diameter Sealing Material (top 50') _ <br />D pih I Filler Material (Below 50') <br />1. <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L)DESTRUCTION El(No septic system permitted if public sewer is <br />�--- E IF available within 200 feet.) , 7 <br />installation will serve: Residence `I Commercial _ Other <br />f 9 <br />Number of living units: �'}Number of bedrooms t <br />Charaater.'f soil to a -depth of 9 feet: `� Water table depth <br />SEPTIC TANK F-1Type/Mfg Capacity No. Compartments I OQ <br />! Method of Disposal <br />PKG. TREATMENT PLT. -7 1 I <br />Distaim -to.nearest: Well- - <br />-FoundationLi <br />Property ne <br />— _ <br />C y J* .� <br />>`TFkHING LINE" C} No �& Length of lines Total length/size - <br />FILTER BED ❑ Distance to nearest: Well Foundation'' 4•J' :'� P.roperty Line <br />SEEPAGErPITS ❑ Depth Size Number <br />SUMPS 'i °w S1 CJ], Distance .io naarei'i "J Well Foundation Property line <br />DISPOSAL PONDS ❑ .. S. <br />II hereby certify that I have prepaied this application and that the work will be'done in accordance with San Joaquin county ordinance laws, and <br />rules <br />regulation$,of,the San Joaquin,Local Health'•District. <br />Home owner or licensed agent's signature certifies the following: e per <br />"I certify that in the 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-contfacting signal <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 compen <br />tion laws of California." I <br />The applicant t call for all requi 'ns t ns_ Complete drawing on reverse side. <br />I Signed X i [� Title: Date: <br />{ FOR DEPARTMENT USE ONLY }� r <br />Date�'r r i Z fi} e `f t Area i <br />Application Accepted -by <br />Pit or Grout Inspection <br />Data Final Inspection by Date <br />1 - <br />Additional Comments: ' <br />❑ Stk 466-6781 13 Lodi 369-3621 ❑ Manteca 823-7104 ED Tracy 836.6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009,VStk., CA 95201 <br />s <br />+ EH 1324 IREV. 1 s s. <br />EH 14-26 <br />FEE <br />AMOUNT DUE <br />AMOUNT REMITTED CR- <br />RECEIVED BY DATE PERMIT NO. <br />INFO <br />