Laserfiche WebLink
v e <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i` 1601 E..HAZE'UTt,ON°AVE., STOCKTON, CA I. <br /> Telephone (203) 466-6781 <br /> V1 PERMIT EXPIRES I�YEAR FROM DATE•ISSUED <br /> k� � 1 <br /> r! �_ ::I,�:„�t�1 •� ��(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. J llr <br /> �0 >� City <br /> Lot Size PM <br /> r- <br /> Job Address 3O / l <br /> la e <br /> Owner's Name <br /> is <br /> 03 ?0 o. <br /> Contractor Z Phone — <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IJ DESTRUCTION ❑ > <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 1_ CONSTRUCTION SPECIFICATIONS <br /> I <br /> ❑ Industrial.,. '” ❑ Open Bottom r_.-❑_Manteca •pia;of Well Excavation' k Dia. of We11 Casing <br /> k rt �„ .; <br /> • / of-a sIn Specifications <br /> CDomestic/Private +l] Gravel Pack ❑ Tracy �'yP9 " t <br /> ❑ Public � , r❑ Other ❑ Delta Depth of Grout Seal �-•---- T YPe of Grout <br /> ❑ Irrigation f. 9. h� ---Approx. Depth ❑ astern S dace Seal Installed byOW/WF4 L) <br /> &tt"�o <br /> Rapai�' v4 Done''! Type of Pump _�x . H.P. T State Work Done <br /> Well Destruction El Well Diameter = Sealing Material (top 501 <br /> Depth Filler NI"a'tenSI-Welow 50'1 Yl <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 171DE6TOPCTION L3 (No septic system permitted-+f public sewer is J <br /> -s.4 x, L..ff ! available within 200 feet.) <br /> d <br /> Installation will serve: Residence' Commercial_----Uther (A <br /> Number of living units: - Number of bedrooms L-J <br /> I <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg f t Capacity No. Compartments <br /> PKG. TREATMENT PLT. 1-1 `•f Method of Disposal <br /> T'.ie� <br /> Distance to nearest: Well Foundation Property Line <br />` LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r f <br /> FILTER BED ❑ Distance to nearest Well Foundatio Property Line <br /> _ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundati n Property Line_' <br /> DISPOSAL P f` ` <br /> hereb ertify that I have prepa d this application and that the work will be donwin accordance with San Joaquin county ordinances, state laws, and <br /> ` rules d regulations of the San J aquin Local Health District. <br /> Ho owner or licensed agent's si nature certifies tha Ilowing: "I c hat in the performance of the work for which this permit is issued, I shall not <br /> em loy any person in such manner a o become su to ork s c pe sation 1a f California."Contractors hiring or sub contracting signature <br /> ce ifies the following: "I c ify t n the pert of k for ich is perm' ued,I sh it a ploy persons subject to workman's compensa <br /> i do laws of California." <br /> The licant m t c ed in ti ever e. / <br /> i <br /> � D at <br /> ' Signed 6 <br /> DEPARTMENT USE ONLY <br /> Application Accepted by DateArea v <br /> f <br /> Pit or Grout Inspection by Date Final inspection by � Date�.2 <br /> i <br /> Additional Comments: <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 Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-241REV.1/85) <br /> EH 14.28 <br />