Laserfiche WebLink
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 /> t and/or install the work <br /> cation is <br /> madeinti <br /> nticompi ante with San Joaqu nnComy Ordinance Noh D549 for sewage oriNo. 1862 for Joaquin Local Healtistrict for a permt to cwell/pump and the Rules and'R gulations of the Sang Joaquin <br /> Local Health District. <br /> r City Lot Size �' PM <br /> Job Address <br /> Owner's Name <br /> t Address, ��'� "�^� �`– Phone <br /> Contractor's Name .—� Q License No. & Phone <br /> TYPE OF WELL/PUMP: 'k 5ti i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ '1. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ u <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other 11T Delta Depth of Grout Seal Type of Grout { <br /> ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by k – 1 <br /> � --,'State Work Done <br /> Repair Work Done Ll Type Type of Pump , <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth <br /> Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ElINo septic system permitted if public sewer is <br /> j� available within 200 feet: <br /> Installation will serve: Residence_t Commercial— Other 3 f f <br /> Number of living units:_/_ Number of bedrooms _. _ e r, Jk <br /> Water tabldepth-= <br /> Character of soil to a depth of 3 feet: Y <br /> SEPTIC TANK ❑ Type/Mfg Capacity No• Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> s ` <br /> Distance to nearest: Well Foundation Property Line t ' <br /> Y �o <br /> ° i <br /> LEACHING LINE No. & Length of lines ��� �Total length/size r <br /> FILTER BED ❑ Distance to nearest: Well�_�-O-Foundation- Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth Size Number <br /> - Li- <br /> SUMPSn <br /> � Distance to nearest: Well t Foundation �� Property ne___ap j �1 <br /> DISPOSAL PONDS ❑ i j <br /> I hereby certify that I have prepared this application and that the work will be done in accatdance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. C <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 i <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 Califo is <br /> Theapplicant m or all r wired inspections. Complete drawing on reverse side. - <br /> _� � Date: r �• 7 f". <br /> E Signed Title: <br /> y ' <br /> € FOR DEPARTMENT USE ONLY <br /> Application Accepted y Date ��"�7�� Area <br /> fDate Final Inspection by Date 12 � <br /> r <br /> Pit or Grout Inspecti y <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 �:AN{011NY DUE—AMOUNT REMrrTED CASH - –RECElVED 8Y R-.= DATE"—'� -'"PERMIT NO. <br /> INFO <br /> ��,.......^.�-•--.,...,..... -- +�..� P,i. ,,k� f -: ., � Z� r' abM i?�'_1 SOS r <br /> - - - -- <br />