Laserfiche WebLink
b <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a 1604E. HAZELTON AVE., STOCKTON, CA <br /> Telephohe (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 /> 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 I <br /> Local Health District. II <br /> CitVQA <br /> Job Address Lot Size PM <br /> �_ 399 <br /> a 1� ddress_ Phone <br /> Owner's Name �j y <br /> Contractor <br /> ,$ Address License No.�—Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 L REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION SYSTEM REPAIR © OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK I� SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION II AGRICULTURE WELL OTHER WELL PITSISU MPS <br /> �„�n,...�.«.,,.�..� ---•�'".fie.'_'=--� <br /> INTENDED_USE_.,_�,.,,�,TYPE_OF_WELL. _PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> - pia. of Well Casing <br /> ❑_industrial Cl Open Bottom D Manteca Dia. of Well Excavation <br /> N T e of Casing Specifications <br /> Domestic/Private Q Gravel Pack O Tracy YP 9 F <br /> f"1 Public [_1 Other C I Delta Depth�of Grout_Seal_ '—_T_ype_of_Grout <br /> Irrigation _..Approx. Depth lJ Eastern Suriac Seal installed by <br /> State <br /> ►Repair Work Done ❑ Type of Pump <br /> H.P. Work Doyle <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Vd ` fir/ <br /> Depth I� ^Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIWADDITION l I DESTRUCTION-hl_(No septic system permitted if public se er is <br /> available within 200 feet.) y <br /> Installation will serve: Residence_ Commercial Other <br /> !Number of living units: Number of bedroloms _ <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I� Capacity No. Compartments " 0 <br /> PKG, TREATMENT PLT. ❑ i iii Method of Disposal <br /> t ' <br /> i< <br /> Distance to nearest: Well Foundation Property Line ; <br /> r <br /> 1 LEACHING LINE LI No. length/size No. & Length of lines � - -- <br /> FILTER BED ❑ Distance to nearest: l' Well '� Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> Foundation Property Line <br /> II SUMPS Cl Distance to nearest:;!, Well Fou <br /> L. .=��DISPOSAL PONDS-�❑= -� .-=--.--•�-� -- <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 taws, and <br /> F rules and regulations of the San Joaquin Local Health District. t i <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 ensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following."I certify that in the performance of the wor permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws alifornia." III' <br /> The ap licantgall! ' ecti ns. CompleteSigned TitDate:R DEPA TMENT USE O LYh1wDate <br /> Application cce <br /> Pit or Grout Inspection by Data Final Inspection <br /> f DEC <br /> Additional Comments: <br /> EIStk 4666781 E1 Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2049; S�k %r A 13201 ttti ; 6 `� <br /> CK 9 <br /> FEE AMOUNT DUE AN!OUNT REMITTED SH RECEIVED BY BATE PERMIT NO. <br /> INFO <br /> I ..EH 13-24{REV.r/n sf <br /> EH 14-26 <br />