Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> =Telephone (209) 466-6781 T " <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> ` (Complete in Triplicate) <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 Joaq in County Ordinance N .549 for sage No. 1862 for well/pump and the Ryles and"Regulations of the San Joaquin <br /> Local Health District. /��/J <br /> CGOL �h �tiS7rr'�( �vt <br /> 1 Job Address t" City Lot Size <br /> PM <br /> Owner's Name Address Phone <br /> Contractor 'dress f ,� f� <br /> f License No.�Phone ; � <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT,❑_ --DESTRUCTION ❑ <br /> PUMP NSTALLATION " `" 'SYSTEM REPAIR`O"� W' OTHER ❑ <br /> x.e .._. � DISPOSAL FLD. �, PROP. LINE .Z%VVV <br />" DISTANCE TO NEARE T: SEPTIC TANK �� <br /> �—..� SEWER LINES d '- L � <br /> FOUNDATION AGRICULTURE WELL " OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA�lCONSTRUCTION SPECIFICATIONS <br /> )d1lndustrial ❑ Open Bottom ❑ Manteca '­_-0 Dia. of Well Excavation Dia. of Well Casing f I HL <br /> ❑ Domestic/PrivateGravel Pack ❑ Tracy Type of Casing Specifications / <br /> ❑ Public ❑ Other E3 Delta " Depth-of Graut-Seal �} T of Grout 40 <br /> ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by C' <br /> Repair Work Done ❑ Type of Pump OW.&E H.P. §tate Work Dobe <br /> Well Destruction ❑ Well Diamet r Sealing Material (top 50') a� <br /> Depth ..dOog Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 2fl0"feet.) <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: r `" - • <br /> SEPTIC TANK ❑ Type/Mfg ` Water table depth <br /> Capacity � No. Compartments <br /> PKG. TREATMENT PLT. ❑ e II <br /> Method of Disposal <br /> Distance to nearest:,^ Well Foundation Property Line <br /> h+ <br /> l . <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth A Size Number <br /> SUMPS ❑ 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, 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:'9 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 applican u -call f r all quired inspections. Complete drawing o rse side. E <br /> Signed Title: Date: 7 C? <br /> FOA"DEP]4 ENT-USE,ONLY <br /> Application Accep Date �' Area <br /> Wpr _ �- <br /> Pit or Grout Inspectio0, y Date Fin Inspection by p <br /> ate <br /> y... <br /> Additional Comments: w - R 4{W <br /> ❑ Stk 4W-6781 ❑ Lodf 3WMI' ❑ Manta 823-7104 Tracy 835-631 <br /> Applicant- Return all Is-to: Environmental Heal#h Permit/Se�'ces 1601 E. {H_aze1n n Ave/", Fi-6. Box_2r009, Stk., CA 95201 <br /> 1 4!!G"C 7 •r o tT+ �3 5 [ 64,r A.10.) f + �3 7 jccl1 <br /> FEE AMOUNT DUE ' AMOUNT REMITTED ! 1 PATE PERMIT"NO. <br /> INFO ." CASH RECEIVED BY <br /> + EH13241REV.t/as] _ - , �� S�y"� 6+'n �^ <br /> EH 1426 <br />