Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 described. This 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. (� l <br /> Job Address T 0igWAIV. City IA 7CWLot Size ��� PM <br /> Ownei Address Phone <br /> . �Contrac 0 &ZFddress License No,_ZSR9%Phone <br /> —TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTR_UCTION ❑ <br /> _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER 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 Dia:of Well Excavation I " Dia. of Well Casing <br /> t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `� Specifications V <br /> 1'1 Public ❑ Other ❑ Delta Depth of Grout eal _ __ , Type of Grout ° <br /> 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by 2 r' <br /> Repair Work Done ❑ Type of Pump H.P. ; - State Work Done <br /> Well Destruction ❑ Well Diameter f <br /> t Sealing Material (top 50'1 <br /> Depth Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION - DESTRUCTION 1-1,(No septic system permitted if public sewer is <br /> available within.200 feet.) <br /> Installation will serve: Residence_ Commercial—4e Other <br /> Number of living units: Number of edro ms ; t <br /> Character of soil to a depth of 3 feet• '. , Water table depth a` <br /> SEPTIC TANK ; ❑ "Type/Mfg Capacity y ' - Nb. Compartments <br /> PKG. TREATMENT PLT. ❑ - Method of Disposal <br /> ?Distance to nearest: Well FoundationProperty Line i <br /> 1 _ � <br /> LEACHING LINE No. & Length of lines ! Total length/size <br /> r , <br /> FILTER BED © Distance to nearest: WeIIC�s Foundation ' Property Line �yZ..; . .. <br /> r SEEPAGE PITS Me,Depth Size _ Number e <br /> SUMPS Cl Distance to nearest: Well ' ° oundaiion. 115' 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 aquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner ar_Iicensed agent's signature certifies the following::-'l 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: " ertify that in the pe mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califor 'a <br /> t <br /> The applica II for all requir specti Co late drawin <br /> Signed X bate: ' <br /> 3 <br /> OR DEPARTMENT USE ONLY <br /> 1 <br /> Application Accepted by Date "'Cy`- _ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: ' <br /> Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-63$5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK 0 <br /> (NFOFEE AMOUNT DUE AMOUNT REMITTED' ' CASH RECEIVED BV �j, DATE PERMIT*NO, <br /> y <br /> r EH 13-24 MEV.t/R51 <br /> EH 14-29 7 x'tF y '� �.✓ <br />