Laserfiche WebLink
� ^ p <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTS <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 /> e ortNo. 1862 for wellipump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewag <br /> Local Health District. <br /> Ave1 City <br /> Lot Size PM <br /> Job Address <br /> 9.0 ". <br /> Q vW t l4ddFess 0 OILI <br /> Phone �� <br /> n <br /> Ower's Name <br /> S <br /> Phone <br /> d� ddress d�JZSC� License No. . ��O ' <br /> Contract <br /> CTION LJ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 13DESTR OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL. -- - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> :Specifications <br /> Well Casing <br /> ❑ Industrial ❑ Open Bottom F1 Manteca Dia. of Well Excavation , <br /> Type of Casing❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 9M Public ❑ Other ❑ Delta Depth.of Grout Seal f Grout — <br /> E I Irrigation __.Approx. Depth I 1 Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SFPTIC WORK: NEW INSTALLATION [] REPAIR/ADDITION ( EI DESTRUCTION (No sbetic systhin m permit <br /> erfeet.itavailaled if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other l <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. L1Method of Disposal <br />` Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line <br /> It , <br /> I SEEPAGE PITS I I Depths ~� —Size m Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS— ❑" `Y <br /> 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 /> I 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, 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: "I 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 California. <br /> kk F <br /> h, The applicant m t call or all re wired inspections. Complete drawing on reverse side. a <br /> i� q 111t>✓t Date: S 3 b d <br /> Signed Title: - <br /> R DEPARTMENT USE ONLYJW <br /> y <br /> ^ Date "` Area <br /> Application Accepted by - p] <br /> Pit or Grout Inspection by bate Final Inspection by Date cr J <br /> Additional Comments: YT <br /> I ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 523-7104 ❑ 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 /> k FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> fk <br /> INFO <br /> rr �n <br /> + EH 13-24 iREV.1/9 5) <br /> EH 14.26 -` '�� <br />