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 ISSUEDW • ' <br /> {Complete in Triplicate) " <br /> Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made <br /> Local in compliance <br /> District. <br /> with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Job Address sa C:`"' E' ffA F <br /> e} City �. (" Lot Size PM <br /> Owner's Name � ,i "Address Phone- - P <br /> Contractor Address License No, <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK L_'SEWER LINES' ~ DISPOSAL FI .LDPROP. 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 <br /> ' <br /> L-1 Public. Specifications --�-, <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -� <br /> El Irrigation <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump - H°P. \'t" State Work Dane <br /> Well Destruction ❑ Well D'rameter� Sealing Material (top 501) r <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Li DESTRUCTION ED (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence IL Commercial— Others OQ <br /> i <br /> Number of living units: Number of hedrd¢ms <br /> Character of soil to a depth of 3 feet: 1 ° fl <br /> Water table depth Ano;, m <br /> SEPTIC TANK Type/Mfg } <br /> ' Capacity No. Compartments► <br /> PKG.:TREATMENT PLT. ❑ <br /> Method of Disposal <br /> ^* Distance to nearest: Well OnoMethod <br /> Property Line ,! <br /> LEACHING LINE ❑ No.i& Length of lines -7 7C,> Total length/size i <br /> FILTER BED ❑ Distance to nearest: Well Foundation --ProperF <br /> ty Line 1 <br /> SEEPAGE PITS ❑ Depth Size i Number <br /> SUMPS' ❑ Distance to nearest: Well FoundationProperty Line <br /> DISPOSAL PONDS ❑ yam;-�� C <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. y <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."Contractors 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 inspections. Complete drawing on reverse side. <br /> g 2✓ <br /> Si n "+ Title: GC 1 �: Z <br /> Dawte; <br /> t FO DEPARTMENT USE ONLY <br /> �I '`.,. <br /> Application Accepted by Date' <br /> " - . .. .. fa <br /> � ..Pit or Grout Inspection by te Final Inspection by Date//�/� y <br /> +, <br /> —'Additional Additional Comments: � <br /> ❑ Stk 466-6781 T❑ Lod ' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copres to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT.DUE AMOUNT REMITTED <br /> INFO �J r� CK <br /> RECEIVED BY DATE PERMIT"No. <br /> EM 74 <br /> + EH 1324 iREV.F%e5S �V - 4 <br /> �b 1 <br />