Laserfiche WebLink
APPLICATION FOR PERMIT ( , �,p a✓ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT / <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or <br /> all the <br /> rk <br /> .This <br /> cation is <br /> made <br /> Application <br /> withdSano the Joaqu n Counguin ty OrdinalHealth District for a nce No.549 for sewage or permit <br /> No. 1862 forcwell//pump and the Rues and IR Regulations of the San Joaquin <br /> Local Health District. <br /> �/`� ,�/ / G <br /> Job Address <br /> "! /'� 1 �/L�U7 d� City•STo�"�— Lot Size L(>� /� PM <br /> '� � IV; 4I��-/ aZ Phone 3/—3� <br /> Owner's Name IN^7 ' f / j�/f�jra•��.tJ�Address <br /> Contractor t� fi Address 3 .411 License No-2_6ST�/ Phone <br /> TYPE OF WELL/PUMP: DESTRUCTIONS ` <br /> NEW WELL JR-- WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION �^ SYSTEM REPAIR ❑ OTHER Elr� <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ll Casing <br /> Dia. of We <br /> El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation NG <br /> Type of Casing------x <br /> asin Specifications <br /> �I'Domestic/Private J�avel Pack El Tracy YP g Type of Grout <br /> f'1 Public F1 Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by UMIAVC CS2Z L4f!1-00� <br /> _ <br /> Repair Work Done L1 Type Work Done Type of Pump `Su'�n H.P. ,..-- <br /> Well Destruction 0' Well Diameter <br /> Sealing Material (top 501 4Cev'" <br /> Depth /2,01 Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) 10 <br /> Installation will serve: Residence_ Commercial_ Other +� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. ElMethod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS C1 Distance to nearest: Well Foundation Property Line <br /> 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 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, 1 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 applicant mus all f a quired inspec'ons. Complete drawing on reverse side. <br /> Signe X <br /> Title:,-5,0 EDate: <br /> FOR DE ARTMEIN SE ONLY <br /> Application Accepted by <br /> Date '— ` Area <br /> 1-791A —X �Pit or rout inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 O 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 AMOUN -REMITTED CASH RECCK IF EIVED BY DATE PERMIT'NO. <br /> INFO _ <br /> �0 3j <br /> + EH 13-24(REV.t/x 5) <br /> EH 14-26 <br />