Laserfiche WebLink
APPLICATION-FOR PERMIT <br /> I SAN JOAQUIN LOCA!HEALTH DISTRICT <br /> I <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466_6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br />'. Application is hereby made to the San Joaquin Local Health District for a . <br /> made in compliance with San Joaquin County Ordinance-No.549 for sewageeortNo. 1862 for well/ and he Rules and Regulations of the San Joaquin <br /> Local Health District. described. TMs application is <br /> Job Address � " !G �� <br /> CityLot Size <br /> - PM <br /> Owner's Name <br /> Address <br /> Phone <br /> Contractor <br /> Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ License No. Phone <br /> WELL REPLACEMENT LJ DESTRUCTION ❑ <br /> PUMP INSTALLATION O _v SYSTEM REPAIR,❑v % OTHER ❑; <br /> DISTANCE TO NEAREST; SEPTIC TANK <br /> � �SEW' LINES `': g:s <br /> Al <br /> �' "DISPOSAL FLD: ' PROP: LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca — <br /> ❑ Domestic/Private El of Well Excavation r Dia. of Well Casing <br /> ❑!Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Public ❑Othsr DeSpecifications <br /> y 0-'Delta 11 Depth of Grout Seal <br /> ❑ Irrigation --Approx. Dept h' '❑ Eastern i Type of Grout <br /> Surtace Seal Installed by <br /> " Repair Work Done ❑ Type of Pump I ' <br /> Well Destruction ElWell Diameter —�� H°P State Work--:Done <br /> ` <br /> ,,. Sealing Material (top 50') ,! <br /> DepthFiller Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system <br /> permitted if publicAwwer�s <br /> Installation will serve: Residence available within 200 feet.) <br /> Commercial_ Other <br /> Number of living units: Number of bedrooms `� N <br /> Character of soil to a depth of 3 feet: Water-table depth <br /> SEPTIC TANK ❑ Type/Mfg -.� � <br /> PlCG.iTREATMENT PLT. E2 Capacity No. Compartments <br /> ` 'Distance to nearest: We11 i Method of Disposal <br /> Foundation Property Line .__5 <br /> LEACHING LINE <br /> ❑ No. � Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> Foundation Property Line. <br /> SEEPAGE PITS ❑ Depth Size ` ' °� I <br /> SUMPS ❑ Di ' Number <br /> stance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that I'have prepared this application and that the'workzwill be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San'Joaquin Local Health""District. ti <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, 1 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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection by ,Date <br /> Additional Comments: f <br /> D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- <br /> ` Applicant- Return 811 copies to: Environmental Health Permit/Services 16D1 E6386 <br /> . Hazelton Ave P.O. Box 2009, Stk., CA 35201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE <br /> PERMIT'iVO. <br /> +EH 18-24 fREV.s/as7 <br /> EH 14-28 ''"' <br />