Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCALMEALTH 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 /> Job Address bx 47 91 <br /> City+ of Size ply <br /> or <br /> A <br /> Owner's Name Address %1 W, Phone i1 <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WEL-L—❑..-- — •-.WELL'REPLACEMENT ❑ r- DESTRUCTION 0- <br /> PUMP <br /> -PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 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 —Approx. Dept ❑ Eastern f Surface Seal Installed by <br /> Repair Work Done 11 Type of Pump H.P. [ State Work Done � �,,, � <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 .L —7—Dr <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is o <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other ,A f <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments V <br /> PKG. TREATMENT PLT. ❑ MiRg5hod-bf D3 so aI. r, i) <br /> Distance to nearest: Well Foundation Prope U. f''LA <br /> LEACHING LINE ❑ No. & Length of lines Total length/siz f 4 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` W <br /> 'T <br /> :SEEPAGE PITS ❑ Depth Number—, j `F??I1Cc, <br /> S <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> contracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub <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 <br /> tion lades of California." workman's compensa- <br /> The applicant st all for a, req 'r inspe i ns. pi to drawing on a si <br /> Signed Title: �� <br /> Date: <br /> - I <br /> FOR D ARTMENT USE ONLY <br /> Application Accepted by Date 3A lr4 Area ' <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additions! Comments: <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, Stk., CA 95201 <br /> FEE AMOUNT DUE ' AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. <br /> INFO CASH <br /> EH 13-24 <br /> EH 1 <br /> + 426(REV.10/831 <br /> ��l b 19, -51 <br />