Laserfiche WebLink
APPLICATION FOR PERMIT -r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 4 YEAR FROM DATE ISSUED , <br /> ' (Complete in Triplicate) <br /> e work <br /> .This <br /> all ih <br /> Application is hereby mcation is <br /> ade to the S n Joaquin <br /> OrdinanHealth District for a ce No.549 for sewage or permit <br /> No. 1862 forcweNapump and the Runes and'R Regulations of the San <br /> Joaquin <br /> made in compliance with San Joaqu county <br /> Local Health <br /> District. <br /> Al 5?7L.J ---�— <br /> �1f V1 City Lot Size PM <br /> Job Address <br /> Phone <br /> L� <br /> Owner's Name �.,.�-.----= Address <br /> Address� � �License No. <br /> y)4- Phone <br /> Contractor'�� DESTRUCTION Q <br /> I TYPE OF WELL/PUMP: . NEW WELL Ll _ WELL REPLACEMENT ❑ <br /> . PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR D OTHER ❑ <br /> k -_-. `-SEWER-L-INES�---��---- .OSAL FLD. PROP. LINE <br /> r DISTANCE TO NEAREST: SEPTIC TANK- AGRICULTURE WE OTHER WELL PITSISUIViPS <br /> FOUNDATION _.�- <br /> INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑-Ma a Dia. of Well Excavation f� <br /> ❑ Industrial r Specifications <br /> racy Type of Casing <br /> O Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout <br /> M Public ❑ Other , = } �R❑ Delta P _ <br /> rox. Depth. ,I 1 Eastern Surface Seal Installed by r <br /> I I Irrigation — State Work Done— <br /> 'i1 H.P. <br /> Repair Work Done ❑ Type of Pump - �'%f", Sealing Material Stop 50'1 <br /> I ❑ Well Diameter <br /> Well Destruction r <br /> Depth �` . Filler Material iBelow 50') <br /> TYPE OF SEPTIC WORK: NEW tNSTALLATION l].REPAIRlADDITION 1 l DESTRUCTION al o septiwi hineni 200 rented if public sewer is <br /> F Installation will serve: Residence✓ Comr-hercial ''Other, V <br /> Number of living units: Number of bedrooms r� Water table depth <br /> Character of soil to a depth of 3 feet: <br /> �, Capacity No. Compartments <br /> SEPTIC TANK 0 Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Foundation Property Line <br /> Distance to nearest: Well I <br /> f <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines -- Property Line <br /> FILTER BED El Distance to nearest: <br /> Well Foundation P Y <br /> Si <br /> SEEPAGE <br /> v Number <br /> SEEPAGE PITS I Depth 1 Property Line <br /> 1 SUMPS Li Distance to nearest: Well Foundation <br /> DISPOSAL PONDS L] <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 /> " Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California. <br /> certifies the following: "'I certify that in the performance of the work for which this permit is issued;l shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must call for all requiredcti <br /> ins ons. Complete drawing on reverse side. <br /> e <br /> Title: — Date: <br /> Signed X— ti j <br /> E� pARTMEM USE-OINLY_,.,,, � �� <br /> Date Area <br /> Application Accepted by - r <br /> Dam ; IN Al Inspection by Date <br /> I Pit or Grout Inspection by q S� �3W-Lc� <br /> Additional Comments: DGS o r lr� <br /> ❑ 5tk 466 6781 ❑ Lodi 3621 .❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to-..Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 1344 IREV.1/85 <br /> EH 1428 <br />