Laserfiche WebLink
APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., TO$KTON, CA SCANNED <br /> Telephone (209) <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is Bance with San Joaquin County O dinalnele Ntpermitealh District for a construct install herein <br /> o.549 for sewage or No. 1862 forwell/pump and the Rul s and R gulations application of he SanJoaquin <br /> made P <br /> Local Health District. q i <br /> l�v �� D City Lot SizeC PM <br /> Job Address � ( ( <br /> 4 L _ Address a � ��5��. p' `�� Phone �,3b`t�b <br /> / it <br /> Owner's Name <br /> 111 -,SQ— <br /> el <br /> Contractor <br /> Address bA�C,License No. Phone <br /> TYPE OF WELLlPUMP: NEW WELL 71 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE <br /> PROP. � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> F-1 Industrial—— '" <br /> '"'D"Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing . <br /> T e of Casin Specifications -S <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type g i Type of Grout <br /> F`l Public ❑ Other. # C1 Delta Depth of Grout Seal C <br /> E 1 Irrigation <br /> -Approx. Depth I Eastern Surface Seal Installed by + <br /> rH P State Work Done <br /> Reppif Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.-I. I REPAIRIADDITION I 1 DESTRUcTiON>QNoseptic <br /> system <br /> rented if public sewer is <br /> l s' <br /> Iristallation will serve: Residence— Commercial— Other a G <br /> Number of living units: Number of-bedrooms <br /> Water table depth <br /> Character of soil to a depth'of 3 feet: <br /> - <br /> SEPTIC TANK 0_ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 1 Distance to nearest: Well Foundation Property Line <br /> � a <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED LJ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L1 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, andel <br /> rules and regulations of the San Joaquin Local Health District. (v <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 /> I 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 applicant t II or a I equir nspections. Complete drawing on reverse side. <br /> Date: <br /> Signed X Title: <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> IData `2 Area <br /> Application Accepted by l <br /> Date Final Inspection b Oats <br /> Pit or Grout Inspection by <br /> Additional Comments: U <br /> ❑ Stk 466-6781 ❑ Lodi -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 AMOUNT DUE AMOUNT REMITTED CASH <br /> EH 13-24(REV. KI RECEIVED BY DATE jPER]�4MITNINFO � <br /> EH 14-28 1l <br />