Laserfiche WebLink
t <br /> � F <br /> APPLICATION FOR PERMIT <br /> r NE <br /> �- k <br /> w 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 f <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. �,r, <br /> YAM. <br /> C; Lot SizJr� a-��MY � �'�Job Address r . <br /> Owner's Namh� fte, <br /> Address�,r �" M Phonv <br /> Contract Y' Address to,4 C' License No.37 � Phone AC'S 1 � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 I <br /> s INTENDED.,USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. 04 Well <br /> Casing <br /> ❑ Domestic/Private L1Gravel Pack 13Tracy Type of Casing Specifications <br /> },: r — � <br /> 1-1 PI ❑ Other ❑ Delta Depth of Grout Seal Type of.Grout <br />' I I trriganon "`�', Approx. Depth I I Eastern Surface Seal Installed by - <br />` Repair Work�C3orie El Type of Pump <br /> H.P. <br /> State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material [top 50') <br /> Depth Filler Material [Below 50'1 i <br /> F :. N <br /> OF SEPTIC WORK: NEW INSTALLATION VT REPAiRlADDITION l l DESTRUCTION l 1 INo septic system permitted if public sewer is } <br /> available within 200 feet.) <br /> lnstaAa`trpn<uvill serve: Residence_ Commercial tither r <br /> PIu'mbef°of`li'ving units: Number of hearoornsi --...-- �J <br /> Faaraptr`of soil to a depth of 3 feet: Water table depth <br /> `SEPTIC1TANK TypelMig f �� Capacity -Avi) No. CompartmentseQ <br /> f PKG. TREATMENT PLT. ❑ Method of Disposal 1 <br /> Distance to nearest: Well%_._ foundation �Q,_-_— Property Line44 —, <br /> LEACHING LINE No. & Length of lines s-• Total length/sizeA2,0 length/sizeXZ <br /> FILTER BED ❑ Distance to nearest: l rest: WelFoundation _. — Property Line <br /> SEEPAGE PITS Depth Size Number.._ �. <br /> SUMPS 0 Distance to nearest: Well /,A' Foundation s- Property-L-ine- ,r`' ; <br /> DISPOSAL PONDS ❑ I f s <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 /> 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 /> The applicants II for all requ 'i pections. Complete drawing on re se side. <br /> Signed X Title: ± _ Date: <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by C/�`^ Date � r � Area <br /> it Grout Inspection by ate inal inspection by CX.-i DIV 7 <br /> ate <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 /> +.I:H 13-24(REV.1/K 5) W I �� <br /> EH 14-26 <br />