Laserfiche WebLink
( APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> f Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> S <br /> madcation is <br /> lication is eieb with e to the San Coe Qty Ordinanuin Local ce No. 549 for sewage or ealth District for a permit <br /> No. 1662 for cwe well/pump and the Rues and Regulations of the San f Joaquin <br /> e in <br /> nce <br /> Local Health District. <br /> �W _Cct <br /> 8 �4 _ City JV Lot Size PM <br /> Job Address <br /> Owner's Name <br /> Address Phone <br /> Address <br /> Contractor 41,11- <br /> _ f License No. Phone% <br /> TYPE OF WELL/PUMP: NEW WELL L) TWELL REPLACEMENT ❑ DESTRUC ON ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS - <br /> INTENDED USE TYPE OF_WELL_,.. ,PROBLEM AREA __ NSTR_UCT10N SPECIFIGATIONS- pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom >E] ante Dia. of.Well Excavation 1 Specifications <br /> cy Type of Casing <br /> ❑'Domestic/Private ❑ Gravel Palk Type of Grout \n <br /> ❑ Other' ❑ Delta Depth of Grout Seal <br /> {i Public t <br /> I I Irrigation _A Depth 4 I Eastern Surface Seal Installed by , <br /> II N.P: State Work Done — <br /> Repair Work Done ❑ ype of Pump P, <br /> Well Destruction _ ❑ Well Diameter Seali;WMateria! (top 50'1 I <br /> Depth Filler Material'(Below 50'1 <br /> i <br /> TYPE OF SEPTIC WORK: NEW l ILPAIfllADDITIO D.ETRUCTION I I aNailabpelwithin 200 feetc system .) if public sewer is <br /> -41 <br /> Installation will serye: Residence_ <br /> . � Commercial'_Other f t <br /> {;¢ <br /> Number of living units: —I/-- <br /> Number of bedrooms �` 7 Water table depth <br /> Character of soil to a depth of Tfeet: - <br /> Capaciy No. Compartments <br /> SEPTIC TANK ❑ TYpelMfg " 1 Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ,ifR <br /> Distance to nearest: Well Foundation:• M -Property Line <br /> LEACHING LINE No. & Length of lines <br /> �. s Total length/size a r <br /> FILTER BED El Distance to nearest: Well '-_` Foundation rr _ Property Line <br /> ` l <br /> SEEPAGE PITS Depth Size Number <br /> s <br /> SUMPS Gl Distance to nearest: Well_ � Foundation� Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 /> ompensation laws of California." Contractor's hiring OF sub-contracting signature <br /> employ any person in such manner as to become subject to workman's c <br /> 1i 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 comperisa- <br /> f tion laws of California." r ~' <br /> The applicant st call for ail required ins ctions. Complete drawing on reverse sid . <br /> Signed <br /> Title: Date: <br /> V" <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> I Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 13 Tracy 835-6385 <br /> i Applicant- Return all copies to: Environmental Health Perinit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Y <br /> FEE CAKSH RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED <br /> F INFO f� <br /> +.EH 13-24 IREV.1 <br /> EH 14-28 <br />