Laserfiche WebLink
I Z55 <br /> ,. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 1' 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATEASSUED ... <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 /> ' <br /> Local Health District '' 3 <br /> I Job Address � � •, `� > g� . 1� .. - <br /> G City X Lot Size PM <br /> Owner's Nam M ddress 7/1 Phone "* <br /> h <br /> Contractor - Address + License No. Phone <br /> s TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ JDESTRUCTION ❑ <br /> x PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom b ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type f Casing Specifications <br /> ❑ Public -❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> t ❑ Irrigation ---Approx. Depth ❑ Eastern �_,S.urface Seal Installed„by <br /> Repair Work Done ❑ Type of Pump H.P. ' State Work Done <br /> I Well Destruction ❑ Well Diameter Sealing#Material (top 50') <br /> t Depth Filler Material (Below 501 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I Installation will servei Residence Commercial_ Other <br /> z _Number of living units: Number of; <br /> bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> ![- SEPTIC-TANK Type/Mfgr Capacity—---- _ No. Compartments <br /> �k PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r LEACHING LINE ❑ No. & Length of lines Total length/size <br /> ` . FILTER BED ❑ Distance'to nearest: Well Foundatiari Property Line <br /> ” SEEPAGE PITS ❑ Depth M Size r Number <br /> fi SUMPS ❑ Distance to nearest: Well F 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 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 /> L 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 applic ust c II all r quir d I pections. golnplete drawingtj,"J,l_..� <br /> everse side. <br /> { Signed - Title: Date: <br /> I FOR DEPARTMENT USE ONLY �( <br /> Application Accepted by Date +' — Area <br /> f. <br /> Pit or Grout Inspection Date Final Inspection by L. 1/1 Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ LV- 69-3621 - ❑ 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 /> r <br /> f ' <br /> FEE AMOUNT DUE A <br /> INFO MOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> f-+ EH 13-24IREV.�ixs7 ®O F <br /> r EH 14-28 S �.��. � ���yp7 .. + <br />