Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—ti AVE., STOCKTON, CA _ <br /> Telephone'(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) applicationcribeis <br /> /or install the work <br /> Application is hereby made to the San Joaquin Local <br /> Nto District54for sewage or permit <br /> No 1862 forcwellldpump and the Rul s and In des R Regula <br /> of the San Joaquin i <br /> PPOrdinance <br /> made in compliance with San Joaquin County <br /> Local Health District. d f <br /> l 5 [�q Al f� Lot Size PM <br /> i 1 A ` �. r City y `` '�Z r <br /> Job Address ��� r f! <br /> N, Phone <br /> �iff Address , <br /> Owner's Name <br /> License No. Phone_ <br /> Address <br /> Contractor WELL REPLACEMENT ❑ OESTAUCTION ❑ <br /> TYPE OF WECLIPUMP: NEW WELL fU OTHER ❑ <br /> MP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES ��— DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER OTHER WELL PITS/SUMPS <br /> FOUNDATION -- AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> Dia. of Well Excavation <br /> C! industrial ❑ Open Bottom ❑ Manteca Specifications <br /> ❑ Tracy Type of Casing - <br /> ❑ Domestic/Private ❑ Gravel Pack Type of Grout <br /> l l Other [� Delta Depth of Grout Seal <br /> [-I Public Surface Seal Installed by <br /> I I Irrigation .-Approx. Depth I 1 Eastern H.P.7 State Work Done <br /> Type Repair Work Done ❑ yp of Pump Sealing Material ftop 501 <br /> Well Destruction ❑,*Welt Diameter Filler MatePial (Below 501 <br /> Depth <br /> TYPE OF 5EPTlC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION LI DESTRUCTION i fNailablelwithin 200 feet.) if public sewer is <br /> Installation will serve: Residence, Commi­ Other�_-- <br /> Number of living units: Number of bedrooms Water table depth <br /> r ^t <br /> Character of sail to a depth of 3'feeVNI x , Capacity— No. Compartments <br /> SEPTIC TANK LIType/Mfg' Method of Disposal <br /> PKG. TREATMENT PLT. Cl Foundation Property Line <br /> + Distance to nearest: Well ��- <br /> Total length/size <br /> ir 1 LEACHING LINE ❑ No. & Length of lines Foundation Property Line <br /> I FILTER BED ❑ Distance to nearest: Well <br /> Size Number <br /> SEEPAGE PITS I I Depth Property Line <br /> SUMPS L-1Distance to nearest: Well <br /> Foundation <br /> F DISPOSAL PONDS ❑ <br /> 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. 1.certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: ii Contractor's <br /> signature <br /> employ any person <br /> sonn sulc e manner hat n the Dario mancecof�he work workman's <br /> for s of Californ <br /> which this permit nsation is issued,i shall employ persons�subject t workman''scompensa <br /> r <br /> certifies the <br /> tion laws of California." <br /> t The applicant must cal for all required inspections. Complete drawing on r verse side. pate: <br /> f Title: <br /> Signed X <br /> (� FOR DEPARTMENT USE ONLY y� <br /> .Date <br /> � ' 1 Area <br /> Application Accepted by Date <br /> k <br /> Date Final Inspection by <br /> Pit or Grout inspection by <br /> os� .7 <br /> Additional Comments: 5.6385, r Q.. .S-� e- �~ <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy } �, J p� <br /> Applicant Return all copies to: Environmental Health permit/Services- E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 fJt Y`"z t-[G <br /> RECEIVED BYj <br /> TE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED AS <br /> INFO � <br /> a EH 13-241REv.tins) v / <br /> 1 14-2e <br />