Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT `f{� <br /> 'f <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 1 <br /> Telephone (209) 466-6781 - C=' � @'` <br /> PERMIT EXPIRES 1 YEAR FROM DATE AISSUEDf � HEALTH. <br /> <<Complete in Triplicate) � V1RONl <br /> .. �ERtJIS!/SERVICES <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 sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. #. - i .V. <br /> 7. <br /> ,33 9/0 X r b o <br /> Job Address City Q Lot Size PM <br /> Owner's Name �� 5 ('16J4. . Address L Phone ,73S <br /> Address SZs �t aLicense No. 62q��1.3 Phone S <br /> Contractor (A0 TYPE OF WELLIPUMP: L�NEW WELWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 f .� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation // Dia. of Well Casing �j O <br /> Domestic/Private ',Gravel Pack X Tracy Type of Casing PVA Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal :7Z * Type of out L <br /> ❑ Irrigation - ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501 <br /> T SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) y <br /> Installation will sery esidence_ Commercial_ Other <br /> Number of living units: bar of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundatio Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/s1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS [I Depth Size Number �. <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line s <br /> DISPOSAL PONDS ❑ <br /> a <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. r <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 /> 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 applic nt 4st call for all requi inspectio s. Complete drawing on averse de. <br /> Signed Title: Date: 7 <br /> OR DEPA MEN T USE ONL <br /> Application Accepted by Date ell /R'7 Area 67— <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional.Comments <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca --104 : ',❑ Tracy 8354KM <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 REMITTEDC SH RECEIVED BY DATE PERMIT''NO. <br /> INFO <br /> +'EH 13-24(REV.1/85) - <br /> �. EH 14-26 <br />