Laserfiche WebLink
APPLICATION FOR PERMIT all <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT D <br /> r <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 2 7 <br /> Telephone (209) 466-6781 SEP i0 - <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH <br /> g (Complete in Triplicate) <br /> PERMIT/SERVICES <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 /> i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> I Local Health District. <br /> o <br /> qq City Lot Size PM <br /> Job Address ` �� � <br /> j zEQ <br /> Phone <br /> Owner's Name Address qq // 2 <br /> I t72 4L.�(2&se No. I S Wanne <br /> 1 Contractor Address <br /> !TYPE OF WELL/PU. P:, NEW WELL_❑ _WELL REPLACEMENT 1,� . DESTRUCTION w_ ;.� <br /> PUMP INSTALLATION ❑ J SYSTEM REPAIR ❑ f O HEFT ❑ <br /> t _ SEWER LINES_ DISPOSAL.FLD. .PROP, LINT <br /> DIS'TANCEETTO_NEAREST; SEPTIC,TANK_�:... - - - <br /> F-�— '2!� PITS/SUMPS fSgJ't <br /> f (h FOUNDATION —_ AGRICULTURE WELL OTHER WELL <br /> is <br /> A, y INTENDED USE T TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p�Jq <br /> - "❑ Industrial <br /> Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private El Gravel Pack 0 Tracy Type of Casing <br /> Specifications ;JD�4 <br /> fl Other 1=1 Delta Depth of Grout Seal f e of Grout .._'�f.v <br /> _"� F`1 Public CSz _ f <br /> I I irrigation <br /> -Approx. Qepth ! I Eastern Surface Seal Installed by_ , <br /> Repair Work Done ❑ Type of Pump H.P. <br /> tate Work Done <br /> Well Destruction ❑ Wel! Diam_ete Sealing Material (top 50' S <br /> ,l _ <br /> Irr :� Depth Filler Material {Be 50'1- <br /> TYPE OF SEPTIC WORK: NEW INSTALLA-IION_I i- REF161R.AQQITI , .J,I„r,DESTRUCTION_[_!�(No_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: <br /> Water table depth r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I Dist a to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length-of lines r <br /> 7 <br /> FILTER BED , ❑ Distance to nearest: Well undation f Property Line <br /> SEEPAGE PITS- I 1 Depth Size -Number— - ' ^} " <br /> SUMPS L] Distance to nearest: !I foundation Pmperry 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-forwhich <br /> this permit is issued, !shall not <br /> t 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 fallowing- "I certify that in the performance of the work for which this permit-is issued`I shall'emplo persons subject to wor man's compensa- <br /> tion laws of Californ- .' I <br /> i I The applicant mu r('ed-i pecti plate drawing on reverse Side. <br /> - Date: <br /> Signed X <br /> I R DEPARTMENT USE ONLY <br /> .- , �7IDS <br /> plication Accepted by o Date C Area <br /> } Date /Q Final Inspection by Date <br /> Pit or Grout inspection by 1 <br /> I Additional Comments: <br /> 0 Stk 466-6781=`R ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy'838-6385 <br /> Applicant - Return-;Il copies to: Environmental Health Permit/Services)601''E.-Hazelton Ave.,-P.O. Box 2009, Stk., CA 955201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIYNO. <br /> INFO <br /> . EH 13-24(REV.1/a 51 <br /> EH"14-211 <br />