Laserfiche WebLink
r-� <br /> APPLICATION FOR PERMIT <br /> SAN J <br /> OAtUIN LOCAL HEALTH DISTRIQqL <br /> 10 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA rN ' '`� <br /> Telephone (209) 466-6781 qa <br /> �'aN .#�OAQU,'N LOCAL X <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUE'(', <br /> (Complete in Triplicate) <br /> EALTH DISTRICT <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 sews ear No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> E'�S p <br /> Job Address Lot Size PM <br /> AV .3Owner's Namet—/G Address Phone <br /> �7 J <br /> Contractor's Name License No. 144 <br /> Z Phone G� C <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ G <br /> PUMP INSTALLATION ❑ t SYSTEM REPAIR ( � OTHER ❑ °r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> —FOUNDATION. AGRICU UTURE WELL OTHER WEL-L� --PITS/SUMPS_:=__ � I4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> RID—omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> ---Approx. Deptq q Eastern Surface Seal Installed by <br /> Repair Work Dane Type of Pump H.P. State Work Done JO L e- G <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 [ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is j <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size e. j <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size ' Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify fhafl have prepared this application and that the work will be done in accordance with San Joaquin county ordinances-state laws;d <br /> rules and regulations of the San Joaquin Local Health District. <br /> — <br /> Home owner or ' se nt's signature certifies the following: "I certify that in the performance of the work`forwhich this permit is issued, I shall not <br /> employ any son in such nner as to become subject to workman'g compensation-laws-of California."Contractor's hiring or sub-contracting signature <br /> certifies the ollowing: 111 cert that in the perfor nce?M_9 work r which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws California." <br /> The appli ant mus call r- I requi�' n plate awing on revAe <br /> . � . v <br /> Signed Title: <br /> Date <br /> FOR DEPARTMEy 9 <br /> Application Accepted by Date _/r�r/�� Area 7 <br /> Pk or Grout Inspection by Date Final Inspection by IOr v Date 07-/19' <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 CK <br /> INFO CASH RECEIVED BY DATE PERMIT"NO. <br /> i <br /> +EK 13-24(REV.10/89) )) y <br /> EH 14-26 `-i - • b 0 <br />