Laserfiche WebLink
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District./. <br /> .5 i1V I .G� 1 ,sJ _City Lot Size PM- I <br /> Job Address - <br /> Owner's Name <br /> Address � — Phone �� { <br /> �j License No. �S� Phone 1 <br /> Contractor's Name r <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION.®-- SYSTEM REPAIR 12�, OTHER ❑ O <br /> DISTANCE TO NEAREST: SEPTIC TANK! SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS ; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing Specifications <br /> >L�DomesticlPrivate El Gravel Pack : <br /> L1 Tracy Type of Grout <br /> ❑ Public ❑ Other El Delta Depth of Grout Seal 4is ,,,❑ Irrigation /4` _�4pprox. Depth ❑ Eastern Surfce Seal Installed by <br /> Repair Work Done ❑ Type of Pump H•p. State Work Done <br /> Sealin Material (to 50'1WeII Destruction ❑ Well Diameter f 9 pDepth Filler Material (Below 50'}TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Noavaseptic ithtem rmitjed if pubj <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms , <br /> I Water table depth <br /> Character of soil to a depth of 3 feet: '`� <br /> SEPTIC TANK ❑ Type/Mfg � Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> a <br /> Distance to nearest: Well Foundation Property Line <br /> 1I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ,I <br /> SEEPAGE PITS ❑ Depth + Size d s Number <br /> SUMPS ❑, Distance to nearest: ' Well S Foundation Property Line <br /> DISPOSAL PONDS Q 1I 1 1. i t <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 /> the San JoaquinLocal Health District. <br /> rules and regulations of <br /> Home owner or licensed agent's signature <br /> i 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:' ify 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 �f <br /> The applicant must II all re or nFspections. Complete drawing on rev. side. ! <br /> f 6 Title: Date: <br /> Signed r <br /> FOR EPARTMENT USE ONLY <br /> Area" <br /> ! Application Accepted by Date <br /> Pit or Grout Inspection by <br /> Date Final Inspection by ate <br /> k Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 83544 r yY <br /> Applicant- Return all copies to: Environmental Health Peimit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201CK -f <br /> FEE AMOUNT DUErl AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> � INFO <br /> 111 S7 �r7-pie <br /> + EH 1324(REV.14/63) <br /> EH 14.26 - <br /> � q <br />