Laserfiche WebLink
4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 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 . t. 61 ity Lot Size PM <br /> Owner's Name Address — �rr'e � Phone <br /> Contiacior ` ,_ "-Address �Q Y License No�gQ-a Phone <br /> TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT LJDESTRUCTION ❑ <br /> PUMP INSTALLATION 'S SYSTEM REPAIR ❑ .OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ISO SEWER LINES DISPOSAL FLD. 'PRO?. LINE US <br /> FOUNDATION 1;1�' AGRICULTURE WELL OTHERrWELL�— PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r1 <br /> ❑ Industrial Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> Specifications <br /> ❑ <br /> :Domestic/Privates El Gravel Pack ❑ Tracy Type of Casing �v <br /> + <br /> Public ❑ O <br /> """-- ' lta'"""-"�1i1""'Depth of Grout Seal' '� '"� Type ofrouE C--GIw. I� _ <br /> � v� ❑ De <br /> ert ,. <br /> .Approx. Depth <br /> 11 Eastern Surface Seal Installed by i n <br /> f I I Irrigation f <br /> Repair Work Done ❑ Type of Pump r — H.P. State Work Done <br /> �. <br /> Weil'Destruction !r ❑ Well Diarnefer eSealing Material )top 50') %C <br /> 4 r Depth ` -�L_j V J .Filler Material (Below 50') "C <br /> ( TYPE OF SEPTIC WORK: NEW INSTALLATION ('a REPAIR/ADDITION ( I DESTRUCTION I 1 Mo septic system permitted it public sewer is <br /> f i � available within 200 feet.) <br /> I <br /> Instillation will serve: Residence Commercial Othef, <br /> . <br /> NumberK of living utnits: Number of bedrooms <br /> Character o . I I _\ - <br /> f soil to a depthtof 3 feet: Wafer table depth <br /> SEPTIC TANK ❑ �TypelNifg <br /> Capacity'. No. Compartments <br /> PKG.ATREATMENT PLT.-❑ � Method of Disposal <br /> Distance tolnear.s, Well Foundation Property Lin <br /> t Totallength/size <br /> J LEACHING LINE ❑ No. 11 Lengf of'lines <br /> FILTER BED © Distance.to nearest:' {Well Foundation Property Line <br /> wok . _ "r <br /> , SEEPAGE PITS l I Depth size Number , <br /> I , <br /> SUMPS Cl Distance to nearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS ❑ <br /> I <br /> I hereby certify that I have prepared this application and that fhe,work wi11 be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. N. \ V <br /> f 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 manneras 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 th'is permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all requir d inspections. Complete drawing on reverse side. , <br /> Signed Title: �G . '" { _ Date: <br /> FOR DEPARTMENT USE ONLY.- <br /> i + Date �� 02 �� Area < <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by Data / <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009?Stk., CA 95201 <br /> CK 4 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO ;�_;U37 <br /> +.EH 13-29 1 REV.1/85} -��- <br /> - EH 14-25 <br />