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.546 for sewage or No. 1862 fo <br /> Local Health District. r well/pump and the Ryles and Regulations of the San Joaquin <br /> // <br /> Job Address � !>a , � f <br /> City Lot Size PM <br /> r r t <br /> Owner's Name Address ��9� <br /> !! ���"t.2. PhoneZ <br /> Contractor Address r li �� <br /> TYPE OF WELL/PUMP: License No Phone <br /> Q <br /> NEW WELL ❑ WELL REPLACEMENT El DES TRUCTION Li <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 1-1 OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑Open Bottom ❑ Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/private ❑ Grave! Pack <br /> ❑ Tracy Type of Casing <br /> ❑ Public ❑ Other ❑ DeltaSpecifications <br /> Depth of Grout Sea! <br /> Ll Irrigation Approx. Depth ❑ Eastern <br /> Repair Work Done ED -Type of Pump Surface Seal Installed by Type of Grout <br /> H.P. State Work Done <br /> Wel! Destruction Q Well Diameter <br /> Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE DF SEPTlC'WORK: NEW INSTALLATION ❑ REPAIR/ADEll TlON DESTRUCTION ❑ ;No septic system permitted if public sewer is <br /> Installation will serve: Residence - .Commercial— Other y available within 200 feet.) <br /> Number of living units:_q__ Number of bedr ms- � <br /> Character of soil to a depth of 3 feet: t i FC; ,. <br /> SEPTIC TANK ❑ TWater table depth._ <br /> Type/Mfg <br /> PKG. TREATMENT PLT. 71Capacity No. Compartments <br /> Distance to nearest: Well Foundation Method of Disposal <br /> Property Line <br /> LEACHING LINE No. & Length of lines / j <br /> FILTER BED Total length/size <br /> ❑ Distance to nearest: We Af Fou ndationr <br /> - �L _ Property Line 'r`s 1�" <br /> SEEPAGE PITS Depth Size <br /> Number <br /> SUMPS <br /> ❑ Distance to nearest.' Well Foundation 10 <br /> DISPOSAL PONDS ❑ Property Line <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."Contractor's 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 mu call for all r uired ' spections. Complete drawing:ZE <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date �� Q� <br /> r Area <br /> (t1i <br /> r Grout Inspection by Date ���� � � <br /> Final Inspection by ?, r Dated <br /> 7 <br /> tional Comments; <br /> ❑ Stk 4W6781 ❑ Lodi 369-3621, O Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK i 1 <br /> INFO CASH RECEIVED BY DATE PERMIT"NO. <br /> +EH 1324(REV.1/85) <br /> EH 1426 I S • v c? <br /> �1 t-e — c <br />