Laserfiche WebLink
APPLICATION FOR PERMIT'. <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> R Telephone (209) 466-6781 <br /> ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f� (Complete in Triplicate) <br /> rk herein <br /> cation is <br /> Application is hereby made <br /> toJthe <br /> a San County Local <br /> ne Health District <br /> for sewage or'No. 1862 fort to cwellldpomp and the Rur install the wles and Regulations of tthe Sanis l Joaquin <br /> made in compliance with q .� <br /> Local Health District. g- <br /> ,, �) f� <br /> City : C " Lot Size PM <br /> Job Address i 7 7 <br /> t <br /> � Phone <br /> Address a✓ 3a JO ��7✓� _ _ <br /> A Owner's Name r <br /> License No._.-�_�Phone_ <br /> Contractor <br /> Zre. <br /> ssTYPE Of WELLIPUMP: EW WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP I gig <br /> SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC T NK AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDA ION <br /> C-CAFICATIONS <br /> INTENDED USE TYPE 01 WELL __ Dia. of Well Casing <br /> ❑ Open B ttom El Manteca Dia. of Well Excavation t <br /> ❑ Industrial ❑ Tracy Specifications - <br /> Type of Casing <br /> ❑ Domestic Private ❑ Gravel ack� 1 Type of Grout <br /> [1 Other; f C1-Delta Depth of Grout Seal <br /> r lic ' t.: +' <br /> appiC i I Eastern Surface Seal installed by <br /> I Irr' atian <br /> H.P.Done Sate Work Done <br /> ;.� <br /> Repo t' <br /> i Sealing Material ltop.54'1 <br /> estru ion ❑ '..WQI iometer K a <br /> h Filler Material (Below 541 <br /> TYPE OF SEPTIC WO available NST'LLATI N 1.1 REPAIR/ADDITION i.I DESTRUCT 70F aNailabperwithin 204 feetc system .) ii public sewer is <br /> Installation will serve: Residence{. Co mercial f Other <br /> Number of living units: f Number,df- edrooms Water table depth <br /> Character of soil to a depth of 3 No. Compartments <br /> ❑ Type/Mfg Capacity <br /> i SEPTIC TANK � Method of Disposal <br /> PKG. TREATMENT PLT. ❑ pro <br /> Distance to near Property V Well Foundation P y Line s <br /> Tot I length/size <br /> ' \LEACHING LINE No. & Length of lines <br /> h } Property Line <br /> FIL` <br /> ' TER BED � <br /> • DDistance to near,st: Well Foundation <br /> EP;LE PITS l I Depth Size <br /> _ ' Foundation Property Line <br /> I SUMPS 0Distance to near st: Well <br /> DISPOSAL PONDS "❑ <br /> I hereby certify that I have prepared this applic tion and that the wo_•rk will be done in accordan a with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Horne owner or licensed agent's signature certi es the following: "I certify that in the performan a of the work for which this permit is issued, I signature <br /> shall not <br /> orrsub-contractemploy any person in such manner as to beco subject to workman's compensation laws of Ca rfarnia." Contra 8°sons sub hiring ect to workman!scompensa <br /> certifies the following: "I certify that in the pert mance of the work for which this permit is issue I shall employ p I <br /> tion laws of California." <br /> ' ns. m to drawing on reverse side. <br /> The applicant C for quirins 9 <br /> - t Date: - <br /> Signed X ; <br /> FOR DEPARTMENT USE ONLY r ; <br /> i <br /> Date Area <br /> Application-Accepted.by <br /> ' Final Inspection by Date <br /> Pit or Grout Inspection by ' Date_�-- <br /> IT µ 14 <br /> Additional Comments: ' 1^' � <br /> ❑ Stk 466 6781 ❑ Lodi 36973621 ❑-Manteca 823- 104 ❑ Tracy 835 6385 <br /> Applicant Ret rm all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95241 <br /> PERMIT'NO. <br /> FEE RECEIVED BY PATE ' <br /> ' AMOUNT DUE AMOUNT REMITTED A H <br /> INFO <br /> ­ER 13-21IREV.t/K51 � V <br /> EH 14-26 <br />