Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6181 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> oaquin Local Health ll the work <br /> ribed.This <br /> madecation is <br /> in compliance with San Joaquin County Ordinance No.Districtn J549 for sewage or No. 1862 for well//pump and he Rules and�RegdMations of the Span'Joaqu <br /> in <br /> made m p <br /> Local Health District. .���p <br /> ,G� =ddress <br /> City G of Size. a / /L�'�� PM <br /> Job Address � J <br /> l Phone <br /> Owner's Name QQ <br /> ` License No.Z26V 3 Phon <br /> Contractor f ddress <br /> WELL REPLACEMENT ®'' DESTRUCTION <br /> TYPE OF LL/PUMP: NEW WELL SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> / SEWER DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION / AICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� <br /> Dia. of Well Casing <br /> E] Industrial Open Bottom ❑ Manteca Dia. of Well Excava "a Specifications <br /> ai-15omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Ll Public El Other <br /> ❑ Delta Depth of Grout Seal Type of out <br /> DOI <br /> ❑ Irrigation ---Approx. Depth 2.9astern SurfaceS al Installed by <br /> H P a-- State Work Done <br /> Repair Work Done ❑ Type of Pump �� --- <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth / Filler Material (Below 501 p@ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system <br /> permitted if public sewer is <br /> avaInstallation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ - <br /> pistance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ED 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 District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance rn the work for which this permit is issued, L shall not <br /> of California."Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws <br /> certifies the followin�Ilfy that in the rmance of the work for which this permit is issued,I shall employ persons subject to workman's Campensa- <br /> tion laws of Califs m <br /> The applicant tll r uir i tions. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY �`W <br /> Date �' Area <br /> Application Accepted <br /> Pit or Grout Inspection y Date 7 Final inspection by Date <br /> r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> v RECEIVER BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24IREv.k/as) �— <br /> EH 1426 <br />