Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) .r- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describ6d. fhis application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �j�J /� �f <br /> Job Address ` ' , /�/" "(/ �4�� City Lot Size�as 41 PM <br /> Owner's Name 'AddressPhone <br /> Contractor ���. Address License No. Phone <br /> TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEM ❑ DESTRUCTION ❑ <br /> PUMP INSTAL TION ❑ SYSTE EPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE REA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications <br /> FI Public ❑ Other l l Delt Dep of Grout Seal Type of Grout ? <br /> I I-irrigation Approx. Depth t I E torn Surface ai Installed by i <br /> Repair Work Done ElType of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIONIK(No septic system 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 <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, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ t <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 Di1trict, <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 /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "Vicertify that in the performance of the work for which this permit is issued, I shall employ i <br /> P p y persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu or d inspe ions. Complete drawing on reverse side. <br /> Signed X Title: l_, Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �� <br /> 41. Area <br /> Pit or Grout Inspe y Date_ Final Inspection In Datq ��f 6 aP <br /> Additional Comments: 2--Q-ct � Ak- C')S-1 <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 AVO., P.D. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH13-21(REV.r 1 K si <br /> - EH 14-28 11,3!5 Q �3 <br />