Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL STEALTH DISTRICT i <br /> 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> GATE ISSUED IP"'1'S <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and ations of the San oaquin Local Hea th istrict. <br /> Job Address A bdivisloq Name <br /> Owner's Name ... r PhoneLy <br /> Contractor' Name icense o. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELLELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> V.1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f <br /> omestic/Private ❑Gravel Pack ❑ Tracy Dia, of Well Casing 11 <br /> ❑ Public ❑ Other ❑ Delta <br /> Irri Type of Casing <br /> V 9ation A Depth ❑ Estern Specifications <br /> ❑ Cathodic Protection <br /> " 1­1 Geophysical Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of PumpH.P. —'! State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 <br /> ordinances, state laws, and 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 <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman5 compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applica must cr all required i pections, Complete dr ing on se s' <br /> Signed x Title: Date: <br /> /� / F D ARTMENT ONLY d->-$ <br /> Application Accepted by Area d� _ ❑ Stk 466-67 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date f/ ❑ Manteca 823-7104 <br /> Final Inspection by �, Q �, � / _ _ Date �/ „� Tracy 835-6385 <br /> Applicant - Return all copi 5 to: Environmental Health Permit/Services 1601 E. Hazelton A/ve.(P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE rP�ERMIfT NO. <br /> INFO Lj <br /> 1 5 V5 to ��� �'I 11J l <br /> EH 13-24 REV. 10/82 (G --7 ` Iv L 10/82 500 <br /> 14-26 1 1� <br />