Laserfiche WebLink
F <br /> APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> rmt i <br /> Application is hereby madeto <br /> the San Joaquin Local Health Joaou'n County Ordinance No.D549 for sewage or 1No�construct 1862 for well/dapplication <br /> pump and the Rules and Regulations of the SanJoaquin <br /> made in compliance with S 430� � <br /> Local Health District. i <br /> Lot Size PM <br /> City <br /> Job Address _ <br /> Phone <br /> Owner's,Name V1 <br /> Address !. <br /> Phone � <br /> Contractor's Name, License No. DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> R PUMP INSTALLATION 71 DISPOSAL <br /> REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> ECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPDia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Type of Casing _ <br /> ❑ Domestic/Private F] Gravel Pack El Tracy Depth of Grout Seal Type 1. Grout <br /> ❑ Public ❑ Other ❑ Delta .� _ – —^ <br /> C1 Irrigation <br /> ---Approx. Depth ❑ Eastern Surface Seal.lnstalled b. r, ,J , � <br /> H P State Work Done <br /> Repair Work Done ❑ Type of Pump r , <br /> Sealing Material Itap 50'1 <br /> Well Destruction [DWell Diameter' <br /> Depth Filler Material [Below 501 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION DESTRUCTION ❑ aNailabPe�with ne2�fee fitted if public sewer is t�11 <br /> Installation will serve: Residence— <br /> Commercial Other <br /> � <br /> Number of living units: Number-of of bedrooms y Water table depth <br /> Character of soil to a depth of 3 feet: _2 , �,t -" _ <br /> �� Z, No. Compartments <br /> SEPTIC TANK ' Type/Mfg }_Capacity fd <br /> t Method of Disposal [ <br /> PKG. TREATMENT PLT. ❑ __,<_r. ,,o _J A/p– Property Line <br /> Distance to nearest: <br /> Well 1sdac– <br /> Total length/size P+ <br /> LEACHING LINE ❑ No. & Length of lines Property Line °' U <br /> FILTER BED Distance to nearest: Well Foundation <br /> C <br /> Size Number <br /> SEEPAGE PITS E3 Depth Property Line <br /> SUMPS Cl Distance to nearest: Well Foundation <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 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 /> i certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> ! tion laws of California." <br /> The applica must call for all required inspections. Complete drawing on reverse side. <br /> Title: - Date: <br /> Signed ~ <br /> FO PARTMENT USE ONLY <br /> Date Area / — <br /> Application Accepted b � p l <br /> Pit or Grout Inspection y <br /> Date Final Inspection b. Date <br /> Additional Comments: <br /> k ❑ 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. Sox 2009, Stk., CA 95201 <br /> FEE =FtEMlTTECCArS*H <br /> RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT bUE AMOINFO <br /> 00 3+ EH 13-241REV.10153) <br /> EH 1426 <br />