Laserfiche WebLink
00 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 �' � <br /> C 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 described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weil/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City A Size PM <br /> a Owner's Name �S `� — Address Phone <br /> icense Phone <br /> Contractor .Address aNo.���� <br /> i TYPE OF NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ _ SYSTEM-REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEVVER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 'AGRICULTURE WELL. OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca A r-Dia. of Well Excavation .Dia. of Well Casing <br /> I'tiiiDomestic/Private ❑ Gravel Pack ❑ Tracy Type-of Casing Specifications <br /> FI Public, Ll Other 17 Delta Depfh of Grout Seal Type of Grout <br /> --- <br /> I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done N <br /> Well Destruction �F4 Well Diameter _ ..- Sealing'Material itop 50'1 - <br /> -- <br /> —" Depth f�0� Filler Material /Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION_ 1.1 REPAIR LADDITION-I.I-- DESTRUCTION l I. (No septic system permitted if public sewer is <br /> v, 0 .- ;_ a available within 200 feet.I <br /> Installation-will serve:-•-Residence Commercial-=--Other—- - !.f <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth (J� <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo, 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 �1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i'1 Depth Size Number E <br /> SUMPS r Distance to nearest: Well Foundation `Property.Line <br /> DISPOSAL PONDS ❑ <br /> s 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 /> t rules and regulations of the.San Joaquin Local Health District. ' <br /> s 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."Contractor's hiring or sub-contracting signature <br /> certifies the following:y'I certify that in the performance of the work for which fts.permit is issued,_/shall employ persons subject to workman's compensa- <br /> tian`laws " <br /> i The applicant requir ns. Complete drawing on re rse de.-Title: <br /> Date:' <br /> I Signed X <br /> I FOR IDEPARTMENT USE ONLY ' <br /> Application Accepted by. c Date r. " Area f� <br /> Pit or Grout Inspection by Date Final Inspection by� . r. Date / <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi.,369-3621M'' ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: EmO or nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT N0. <br /> INFO p� CASH <br /> r EH 13-24/REV:t/nsl <br /> EH t4-2e <br /> r ` <br />