Laserfiche WebLink
APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 MM6City Lot Size PM <br /> Owner's Name Address Wyk Phone <br /> Contractor 'T Address 1` ,T&tl icense IVo. Phone ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ {� <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 y. <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing T <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth. Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permFer isavailable within 200 feLeInstallation will serve: Residence_ Commercial_ OtherNumber of living units: Number of bedroomsCharacter of soil to a depth of 3 feet: Water table dept <br /> SEPTIC TANK K Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � _ , Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines - 'Total lengthisize <br /> I FILTER BED' ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <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 /> 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 /> 1/10, ow <br /> The appiica t must c or all required ins' ctions. Complete drawl reverse side. <br /> Signed Title 1f+ ,i - Date: �. Z�.��7 <br /> � <br /> ,41 FOR DEPARTMENT USE ONLY <br /> v 3 Area <br /> Application Accepted by Date QQ <br /> Pit or Grout Inspection by Date Final Inspection by �"��"t� _ Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lod4 369-3621 anteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C= RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH1 <br /> 3-24(REV.t/65) . 00 �''� i 7 S`7 <br /> EH 1426 <br />