Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br />` Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM'DATE ISSUED° <br /> G k <br /> {Complete in Triplicate) . <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct a11pu install the work herein described.This application is <br /> 1 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862f or wellpump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> ze y � r . <br /> I32`7 PM <br /> Cit <br /> '} Lot Si <br /> Job Address — <br /> .- <br /> 1Address/+ze``L,� � - Phone WO <br /> Nam <br /> i : nr� <br /> Contractor <br /> Address 7 License No. . Phone <br /> TYPE OF WELL/PUMP: NEW WELL 15 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t PUMP INSTALLATION I)t SYSTEM REPAIR p4- OTHER ❑ _ <br /> DIS_TANCE TO NEAREST. SEPTIC TANK --SEWER LINES DISPOSAL FLD. PROP..wC.INE- <br /> } FOUNDATION AGRICULTURE'WELL OTHER WELL PITSISUMPS <br /> r <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial <br /> LlOpen Bottom ❑ Manteca .Dia. of Well Excavation Dia. of Well Casing <br /> OL Domestic/Private ElGravel Pack LlTracy Type of Casing Specifications <br /> ` ❑ Public ❑ Other <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> LI Irrigation ---Approx. Depth ❑� Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump, L — H.P. State Work Done l!� <br /> I Well Destruction - ❑ Well Diameter 4,) - Sealing Material Itop 50'1 _ <br /> Depth Filler Material (Below 50'? <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Q.T REPAIR/ADDITION EIDESTRUCTION Ll (No septic system <br /> m rmi ted if public sewer is U1 <br /> eet <br /> Installation will serve: Residence I Commercial s'.Other <br /> Number of living units: Number of b_edrooms � <br /> Character of soil to a depth of 3 feet: V - Water table depth <br /> .: " No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> M Method of Disposal " <br /> PKG,TREATMENT PLT. ❑ � ' <br /> I f fV" a Property Line <br /> Distance to nearest: Well r. Foundation P Y <br /> LEACHING LINE ❑ No. & Length of'lines -==---' Totd length/size <br /> FILTER BED LlDistance to nearest: Well Foundation `$ Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> ` -. �+ Foundation Property Line° <br /> SUMPS,:. _ ❑ Distance tanearest:,;F'.Well_- - - <br /> DISPOSAL PONDS ❑ # Y" <br /> I 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 /> ,I 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 perfdrmance 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." y} <br /> The applicant m st c or all required inspections. Complete drawing on rev rse side. <br /> Title: , � _ Date: l f <br /> Signed X — <br /> FOR EPARTMENT USE ONLY <br /> I Application Accepted by <br /> Area <br /> Ipate Final Inspection Date • <br /> Pit or Grout Inspection by <br /> i <br /> Additional Comments: - <br /> a i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 -+• <br /> FEE AMOUNT DUE AMOUNT REMITTEDCrICIE) RECEIVED 8Y DATE PERMIT`NO. <br /> INFO '- <br /> + <br /> + EH 1324(REV.118 50 <br /> EH 14-28 - - <br />