Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON,AVE., STOCKTON, CA �� ��� <br /> Telephone (209) X66-6781 <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 City ^ Lot Size ( PM <br /> Owner's NameW/ Address Phone <br /> Contractor_mel ' Address ?- 6 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r <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 v1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _..Approx. Depth -.1.1 Eastern_ Surface Seal Installed-by- <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done Y <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material /Below 501 — <br /> Nk <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t REPAIRIADDITION I I DESTRUCTION I (No septic system permitted if p6blic sewer is <br /> ailable within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth \ f <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT:PLT. ❑ K– Method of Disposal <br /> ^ Distance to nearest: Well Foundation Property Line <br /> s <br /> LEACHING LINE ❑ No. & Length of lines Total length/size j <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size - _.. T Number <br /> SUMPS L] Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 Di1trict. j <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 /> 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." <br /> The applicant must call for all required ins tions. Complete drawing on reverse side.IT <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: , !!t Z V <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ 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 RECEIVED BY DATE PERMIT'NO. <br /> INFO SH <br /> +.EH 13-24 IREV.i i n sl <br /> EH 14-26 <br />