Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE4TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> uin /or install the work <br /> .Thris application <br /> made Application omp once with San Joaquade to the in County Ordinan Joaqnce No.District Health 549 for sewage or permit <br /> 1862 for cwell/dpump and the Rules and IR Regulations of he Sanl Joaquiln <br /> Local Health District. <br /> Job Address Q��(/ 2G City Lot Size PM <br /> ' <br /> �V 1 <br /> - GCA � 2Address g� Phone <br /> Owner's Name �j <br /> Contractor's Name License No. <br /> Phon <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR De- 1 OTHER`❑ G <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FCD. PROP. LINE <br /> . <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> EI Industrial ❑ Open Bottom L] Manteca Dia. of Well Excavation <br /> Type of Casing - Specifications <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Grout , l <br /> ❑ Public El Other [I Delta Depth of Grout Seal Y YP J <br /> ..s <br /> ❑ Irrigation ---Approx. Depth [2--Eastern <br /> -Estern Surface Seal Installed by <br /> i <br /> H.P.Repair Work Done ❑ Type of Pump .' <br /> ,s State Work Done S <br /> ` Well Destruction ❑ Well Diameter. l Sealing Material {top 50'1 DO <br /> Depth Filler Material (Belo 501 , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0. DESTRUCTION 0 (No sepelwth nem permitted if public sewer is <br /> Installation will serve: Residence— `Commercial_ Other 1 i <br /> Number of living units: Number of bedrooms �� i <br /> .. r Water table depth 1 <br /> Character of soil to a depth of 3 feet: v ` <br /> ❑ Type/Mfg Capacityf No. Compartments j <br /> ' SEPTIC TANK. Method of Disposal ` <br /> PKG. TREATMENT PLT. ❑ Property line <br /> Distance to nearest: Well Foundation <br /> T h <br /> LEACHING LINE ,` No. & Length of lines Total length/size r� <br /> -� �} i property Linec�— <br /> FILTER BED ❑ Distance to'nearest: ,'+Well Foundation p <br /> 4 `3 <br /> ( Kirber i <br /> ' SEEPAGE PITS Depth SUMPS ❑ Distan� ize <br /> to nearest: Welles Foun •�dation Property Line �. . <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> I 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, l shall not <br /> employ any person in such manher as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following:"I certify that inahe performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." r <br /> • `� ' O�' <br /> The applicant must call for all dins tions. Complete drawing on reverse side <br /> Title: Date: <br /> r <br /> Signed <br /> l� <br /> FOR DE ARTMENT USE ONLY <br /> t Area <br /> Alication Accepted by Date <br /> pp <br /> r Date <br /> r Grout Inspection by ' r <br /> to/ Final Inspection by <br /> /P'iyb - — <br /> Additional Comments: <br /> ❑ Stk 466-fi7$1 ❑ Lodi 369-3621 El Manteca 623-7104 ❑ 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 CK RECEIVED BY DATE PERMIT`'NO. <br /> )NFO AMOUNT DUE AMOUNT REMITTED CASH <br /> } + EH 1324 4REV.1018X <br /> 4 EH 1 .26 <br />