Laserfiche WebLink
+ S t <br /> APPLICATION FOR PERMIT ,. <br /> •s SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA i <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 Cf Lot Size PM <br /> Owner's Nam Address � _ Phone <br /> ` r� icense i �—PGoge`� <br /> Contractor Address <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 PlT <br /> i <br /> INTENDED USE TYPE OF WELL' "PROBLEM AREA CONSTRUCTION SPE S <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel-Pack ❑ Tracy ype of Casing Specifications <br /> M Public Cl Other - elta Depth of Grout Seal Type of Grout <br /> I I Irrigation — . Depth l I Eastern Surface Seal Installed by— <br /> Repair <br /> y Repair Work Done ype of Pump H.P. State Work Done <br /> Well Destru ❑ Well Diameter Sealing Material Stop 501 <br /> Depth Filter Material (Below 50') ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:i REPAIR/ADDITION LI DESTRUCTIO iNo septic system permitted if public sewer is <br /> available 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: 4M A Water table depth <br /> SEPTIC TANK X,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 length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> 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 /> The applicant u t call for all required in ctPons. Co plate drawing on reverse <br /> Sign Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ^� Area <br /> Pit or Grout InspectionDate Final Inspection by Af — Date <br /> Additional Comments: v <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 REMIT-TED CIC 0 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br />' + EH 13-24 fREV.tiH51 � p(� <br /> EH 14-26 <br /> k <br />