Laserfiche WebLink
N <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT +' U <br /> } <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ' Telephone (209) 466-6781 (.:•�� � <br /> PERMIT EXPIRES 1 YEAR FROM DATE_ ISSUED <br /> (Complete in Triplicate) y <br /> to construct and/or install the work <br /> . This <br /> tion is <br /> madeApplication <br /> in coo iliance with Sanmade othe)aquinnJoaquin County OrdinanHealth District for a ce No.5549 for sewage or permit <br /> o. 1862 for well//pump and the Rules and IR Regulations of he SanlJoaquin i[ <br /> made i p s� <br /> Local Health District. /�pn <br /> Job Address <br /> �(d�oG7 City Lot Size c PM <br /> Q�e O Address ` Phone `l <br /> Owner's Name F,1 � y ' <br /> 6galu //i License No. /�f�Lg — Phoned <br /> Contractor's.Name <br /> ' TYPE OF WELL/PUMP: NEW WELLY r WELL REPLACEMENT ❑ DESTRUCTION .❑ <br /> PUMP INSTALLATION - SYSTEM RFPW ❑ OTHER ❑ (� <br /> DISTANCE TO NEAREST: SEPTIC TANK A� SEWER LINES Al f DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL'—' = PITS/SUMPS 'r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation <br /> �� Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack1 ❑ Tracy, y y Type of Casing Q Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> r Type of Grout' 61~Al <br /> ❑ Irrigation .4,�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 /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nosbptic sy tem emitted if public sewer is <br /> avar 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 /> Ca acity .No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg p <br /> PKG. TREATMENT PLT. ❑ Method 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: WeII Foundation Property Line <br /> SEEPAGE PITS ❑ Depth 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:"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 st call for all required inspection . Comple drawing on reverse side. <br /> Signed <br /> ` <br /> Title: n Date: <br /> FOR DEPARTMENT USE ONLY <br /> d111— CAP <br /> Application Accepted Dateg!k,� <br /> Area <br /> PR o Grout-Inspection y T Date Final Inspection by Date! <br /> F Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El 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 AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. <br /> INFO _9s9 <br /> 1 u . <br /> + EH 13.24(REV.101831 b�, o0 3� <br /> EH 1426 <br />