Laserfiche WebLink
/6 <br /> APPLICATION FOR PERMITEF N <br /> x . SAN JOAQUIN LOCAL HEALTH DISTRICT RE�CEIVZD <br /> ( � 1601 E. HAZEL T ON AVE., STOCKTON, CA ED <br /> Telephone {209) 466-6781 AUG <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED J <br /> 'ENV1RpNMI <br /> ` (Complete in TripFcate) rk � �� <br /> ation is <br /> Application is hereby made to the San <br /> C Joaquin Local <br /> lne Health District <br /> for sewage or it t 18&2 construct <br /> and/or pump and the Rules and Reall th gulation San Joaquin <br /> made in compliance with San JoaquintV <br /> Local Health District. R <br /> - IX1 CityJI"(111 JJ Lot Size PM <br /> Job Address <br /> * II # , <br /> AddressgY l f' :ZiPhone <br /> Owner's Name /� f _ <br />` /�� �Address d 'License No. n l Phone <br /> Contractor <br /> CTION LJ <br /> TYPE OF WELL/PUMP: WELL NEW V WELL REPLACEMENT LJDESTR OTHER ❑ <br /> PUMP INSTALLATION 13 SYSTEM REPAIR El OTHER <br /> ` J, pISPOSAL FLD. A00 .-- PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION,J5 Dia. of Well Casing <br /> l <br /> CI industrial I] Open_Bottom ❑ Manteca Dia. of Well Excavation Asa -- <br /> Type of Casing �y Specifications <br /> Domestic/Private, Gravel Pack Tracy yp g Type f Grout ` <br /> M Public �e Other ❑ Delta Depth of Grout Seal �� YP 4 <br /> Approx. Depth I i Eastern Surface Sea! Installed by <br /> i I Irrigation �1 <br /> Repair Work'Done ❑ Type of Pump H.P. State Work Dane <br /> ' <br /> j f terial (top 501 <br /> Well Destruction ❑ Wel! Diameter Sealing Ma <br /> C <br /> fk Depth Filler Material (Below 501 <br /> TYPE-°OF SEPTIC WORK. NEW INSTALLATION I_I HEPAIRIADDlTION i I DESTRUCTION I I alvailablelc system wthin 200 feet.) if public sewer is C <br /> Installation will serve: Residence_ Commercial_ Other T <br /> 1 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - <br /> PKG. TREATMENT PLT. LI Method of Disposal <br /> F Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I 1 Depth Site — Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> I 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 Di§trict. <br /> t 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 compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the follow' g: "1 certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's <br /> compensa-tion law `of Calif mia." ` <br /> r The applic t call for all'required i ctions. Com eta drawing on r verse e. �_ ` 9 <br /> Signed X <br /> Title: Date: :, —L� <br /> - EPARTM T U NLY <br /> Application Accepted by ` Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: "` <br /> a. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/�5.ervy s 1 1 E. F,ja n'Av�IPPd 0,4G� Stk., CA 95201 <br /> CII <br /> 70 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVEDBY DATE PERMIT N0. <br /> INFO h <br /> •.EK 13-24(REV.1/x 5) <br /> EH 14-25 <br />