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) <br /> t to <br /> Application is hereby made to the County OLdinan Jo ilnce No.549 for sewage or'No. 1862 forcand/or herein <br /> Health District for a welllpump and the Rules and Regulations of the Sanl Joaquin <br /> made in compliance with San Joaquin <br /> Local Health District. .d97 PM <br /> City '"`���' Lot Size.��- �" II <br /> Job Address d� js 1 <br /> LfT� Phone -7J <br /> Address <br /> Owner's Name ���,,,�q e� <br /> ContractorA_ kj Address <br /> f / , License No,ZW,6? Phone �a <br /> NEW WELL ❑ WELL REPLACEMENT LJDESTRUCTION ❑, <br /> TYPE OF WELL/PUMP: PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13 <br /> SEWER--LINES - •'—DISPOSAL-FLD. """"PROP. L'1NE""" <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 /> ❑ Industrial ❑ Open Bottom L1 Manteca Dia. of Well Excavation Specifications <br /> [71 Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> C-i Delta � �` Depth of Grout Seal Type of Grout <br /> n Public (=l Other - Q <br /> I I Irrigation _..Approx. Depth l I Eastern Surface Seal installed by Q <br /> H P State Work Done <br /> Repair Work Done El Type of Pump / <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top-50') �t <br /> Depth Filter Material (Below 501771111111111111- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I' DESTRUCTION' availableNo lw hin 200 feetc system .) if public sewer is <br /> 1 <br /> Installation vvi6 serve: Residence— Commercial Other��� <br /> Number of living units: -- "'Number of bedrooms F <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation p y <br /> t <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> ? FILTER BED ❑ Distance to nearest: Well Foundation <br /> SEEPAGE PITS l l Depth Size <br /> SUMPS Ll Distance to nearest: Well <br /> Foundation Property Line <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'coGrity ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <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, l 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 /> I certifies the following. "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws <br /> oor a." <br /> The appli-- ust call for all�spections. Complete drawing on reverse side. <br /> t Title: Date: 7-111 r�"7 <br /> Signed ; <br /> FOR DEPARTMENT USE ONLY <br /> Date - Area <br /> Application Accepted by <br /> t "o= - <br /> Pit or Grout Inspection by —Date-"— - Finahinspection by- <br /> F <br /> Additional Comments: �- c �, <br /> C1Stk 466-6781 C3 Lodi 369-3621 11Manteca c823-7104 0 Tracy 835-6385 ,w <br /> ' Applicant Return all copies to: Environmental Health PermitLServices 1601.E Hazelton Ave., P.O. Bax 2W% Stk., CA 95201 <br /> i <br /> FEECK RECEIVED BY DATE ?ERMIT'N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> t EH 13-241REV.t/R5) �5`Ua <br /> r EH 14-26 <br />