Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> .This <br /> t and/or <br /> all the work <br /> n desc <br /> is...,– <br /> Application intiom!lance with Sano the Joaquin nJoaquin County Ordinance lHealth No.District 9 for sewage or permit <br /> No. 1862 forcwell//pump,atnd the Rules and IR gulations of the San�Joaquication n <br /> I made P <br /> Local Health District. <br /> �O CJ 4 D L� Q city ,�Gi!e Lot size <br /> Job Address <br /> Address <br /> Owner's Name ✓� C�.y Cl�i�'�,Cf U�� S Phone�lv <br /> Contractor's Name <br /> License No. Phone <br /> TYPE OF WELL_/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 71SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> % FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE' 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> EJ Industrial 13 Open Bottom ❑ Manteca Di,`',of-Well Excavation <br /> Type of Casing Specifications <br /> _ <br /> El Domestic/Private ,❑ Gravel Pack 11 Tracy F,. Type of Grout <br /> El Public El Other ❑ Delia 7 --.j '• Depth of Grout Seal yp <br /> ❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> c <br /> Repair Work done ❑ Type of Pump H P State Work Done "1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 C <br /> Depth - , - T 'Filler Material {i3elow 501 U <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION}K REPAIR/AUDITION ❑ DESTRUCTION ❑ aNailable septic <br /> hit <br /> sysm <br /> r iitted if public sewer is <br /> Installation will serye: Residence� Commercial Other <br /> cial_ = <br /> Number of living units:_ VNumber of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth O <br /> ❑ Type/Mfg <br /> { �= <br /> Capacity—/-- 6fl0. No. Compartments <br /> SEPTIC TANK <br /> '� Method of Disposial <br /> PKG. TREATMENT PLT. ❑ ,L-- <br /> Distance to nearest:. Well Sof/ Foundation ( � ' Pro party Line <br /> LEACHING LINE Vr­ No. & Length of lines _ <br /> Total length/size— <br /> FILTER BED ❑ Distance to nearest: Well oundation Property Line _ C <br /> k2� Size Z S umber ` G <br /> SEEPAGE PITS Depth <br /> SUMPS Ll Distance to nearest: Well g6— Foundation_4( 1 Property Line <br /> DISPOSAL PONDS ❑ <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin unty ordinances, state laws, and <br /> rules and regulations of the San Joaquin'Local Health District. <br /> E <br /> sed agent's signature certifies the following: 111 certify that in the performance of the work for which this permit is issued, I shall not <br /> l 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:"1 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 Ca ifornia." <br /> The applica ust ca for all r uired inspections. Comple rowing on reverse side. <br /> Signed <br /> Title: . ����� Date: <br /> i FOR DEPARTMENT USE ONLY { 3 <br /> Application Accepted by _ <br /> Date ` rea U <br /> Pit or Grout Inspection by <br /> ate Final Inspection by Data <br /> Add'ional Commen <br /> I' �466- l ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 6385 <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ffff �' <br /> FEE CK# RECEIVED BY DATE PERMIT"NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> +EH 13-24 IREV.101831 <br /> ,S <br />