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 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 City Lot Size PM <br /> x Owner's Name Address ��Q � /JtJ Phone <br /> VV <br /> t <br /> Contracto Address ��� License No. Phone <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 R� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS '�} <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 7­CONSTRUCTfWSPECIFICATIONS­ <br /> El }r <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia!of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t <br /> ❑ Other { <br /> M 1 Public I Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _..Approx. Depth i I Eastern i Surface Seal Installed by 1 - <br /> Repair Work Done ❑ Type of Pump H.P. t State Work Done I <br /> � 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 - <br /> Depth } Filler Material (Below 50') <br /> 7.. <br /> NEW INSTALLATION t l REPAIRJADDITION I.I DESTRUCTION (No septic system permitted if public sewer is <br /> `� i-avai6ble within 20dfeet-) <br /> n all serve: Residence X Commercial __ Other <br /> Number of living units: _L_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: I Water table df pth <br /> SEPTIC TANK ❑ Type/Mfg: Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ E Method of Disposal <br /> Distance to.nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well I Foundation Property Line <br /> SEEPAGE PITS l I Depth 1 Size <br /> SUMPS Cl 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 Di-Mrict. f <br /> Home owner or licensed agent's signature certifies the following: "I certifyyth 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 com' ensation 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 t4iis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." \.�� �. ``""� <br /> r � <br /> The app' st call for all requir d inspections. Go�plete drawing on rreev���si�de. •- <br /> Signed 1 Title: �/LJ _ Date: I <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by U—AL-JiCMI_ Date Area- — ' <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments-.. <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 pUE AMOUNT REMITTED CASH. RECEIVED BY DATE PERMIT'NO. I <br /> INFO /drys / <br /> +.EH 13-24 IH EV.1/k51 ,(j� ' �,(f� <br /> EH 14-26 ww f� <br />