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 /> t. (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.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City t 5izeq �' PM <br /> Owner's Nam ess` Phone <br /> ContractorAddress License No. Phone <br /> TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ©I' <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �s <br /> :.DISTANCE-TO-NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other " ' ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ___4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> 1 Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑�(No septic system permitted if public sewer is <br /> `available within 200 feet.) <br /> Installation will serve: Residence_X Commercial_ ther <br /> Number of living units:I Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK i El Type lMfg Capacity_ ° A No. Compartments <br /> k PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE t ❑ No. & Le'ngth of lines Total length/size S P� <br /> EtL' R [ Distancerto nearest: WellFoundation Property Line <br /> SEEPAGE PITS t ❑ Depth Size t Number <br /> - <br /> SUMPS ❑ Distance to�neares4: Well < Foundation" r Property Line <br /> DISPOSAL PONDS ❑ t i 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 /> rules and regulations of the San Joaquin Local Health District.' ' <br /> Home owner or licensed agent's signature certifies the following: "1 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 subcontracting signature <br /> certifies the following: "I certify that in the perfor ce of the work for which this permit is.issued,I shall employ persons subject to workman's compensa• <br /> tion laws of California." ' n <br /> The appl' Zt call f r all required i tions:Complete drawing,on-reverse side. <br /> Signed Title- /k-�.t c�[i�r/. Date: <br /> 11 FOR DEPARTMENT USE ONLY <br /> s <br /> 177 <br /> Application Accepted by ` r Date /•�� r TrArea <br /> ` Pit or Grout Inspection by + Dates`W" —"""`Final-Inspection by Date 1 <br /> Additional-Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621. 0:,Manted823-7104 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 14301 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIV NOf <br /> t INFO <br /> + EH13-241REV.t/e5l �Q� OQ � <br /> l EH 14-28 /// <br /> i <br />