Laserfiche WebLink
APPLICATION FOR PERMIT <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> I Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 4�dnJ ; <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 N . 549 for sewage or No. 18 2 for well/pump and the Rules and Regulations of Sart Joaquin <br /> Local Health District. <br /> t r �, � l� " 77 <br /> Cityty Lot Size s PM <br /> r Jab Address �( � <br /> kC/�1 ddress d rte"z hone <br /> I Owner's Name � <br /> ,F�` l�-,ddress lJ License No.�� Phone ®/! <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT EJ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHEr ❑ 1 <br /> SEWER LINES �� DISPOSAL FLD.�// PROP. LINE Z//r'� <br /> ! <br /> DISTANCE 70 NEAREST: SEPTIC TANK -� PITSISLIMPS <br /> ! FOUNDATION AGRICULTURE WELL --- OTHER WELL <br /> I - lr <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> ❑ Open Bottom Ll Manteca Manteca Dia- of Well Excavation Dia. of Well Casing — <br /> - <br /> L7 Domestic/Private LlGravel Pack ❑ Tracy Type of Casing _ Specifications <br /> Public <br /> ll Other Cl Delta Depth of Grout Seal _DAQ Type of Grout <br /> I Irrigation 40"Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump T/12 BIl&H•P. State Work Done _ <br /> Well Destruction ElWell Diameter _ Sealing Material ltop 50'1 <br /> Depth Filler Material (Below 501 -- �' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DEavailable <br /> I i septic system permitted if public sewer is <br /> available within 200 feet.l <br /> r. Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I <br /> PKC. TREATMENT PLT. ❑ Method of Disposal. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 8 <br /> SEEPAGE PITS 1 I Depth Size Number v <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El <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 /> fy that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certi <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 applicar� f all r rre ctions. Complete drawing on re or side. <br /> a � <br /> Date: <br /> ' Signed X tle: <br /> DEPARTMENT USE JNL <br /> Application Accepted by a Date `��p Area <br /> I 77r"'� - Date GD n by Date <br /> Pit or Grout Inspection by Final lnspectio —. � <br /> { Additional Comments: o <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMiT'NO. <br /> INFO CASH <br /> �.EHM241REV.1/A51 1©.5, p D '��0� <br /> EH 14-26 I <br />