Laserfiche WebLink
APPLICATION FOR PERMIT <br /> ap9 fpm <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ti 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. / S <br /> Job Address City Lot Size xFt PM <br /> Owners Name /t.0/V. C—l,�j?[�/E-Address &ILY Phone r3 T <br /> kContractors Address License No. Phone — <br /> TYPE OF WELL/PUMP: NEW WELL 79 WELL REPLACEMENT 11DESTRUCTION EI <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK `T` SEWER.LINES �� DISPOSAL FLD.I�PROP. LINE <br /> ip yE�g FOU.NDATION_�_AGRI,CU_4TUf,LE-WELL.�OTI1ER WELL .:�f�P17S/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIACATIO%S <br /> T� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> F jf Domestic/Private X Gravel Pack ❑ Tracy Type of Casing G Specifications <br /> 1'1 Public 1-1 Otrer ❑ Delta Depth of Grout Seal Type of Grout,� �� <br /> I I Irrigation AO-Approx. Depth l 1 Eastern Surface Seal installed by �/� <br /> Repair Work Done ❑ Type of Pump ::W43 H.P. Z State Work Done <br /> r <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> j. Number of living units: Number of bedrooms D `I <br /> Character of soil to a depth of 3 feet: Water table depth ! <br /> SEPTIC TANK L,_,YType/.Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. CI ;, t Method of Disposal <br /> t.ttce ce "-'` � <br /> Distato nearest: Well A ,Foundd <br /> ation Property.Line <br /> ffY <br /> LEACHING LINE ❑ No. R Length-of-irnes R'�"�-"~ f l Total length/size <br /> FILTER HED ❑ Distance-tb�nearest: Well f Fotindation Property Line <br /> SEEPAGE PITS- l 1 'Depth,- I 1 SNumber <br /> E SUMPS� "`���� ❑ 'Distance to;nearest:, Well, Foundation Property Line <br /> DISPOSAL PONDS ❑ j;rr <br /> I hereby certify that,"ave <br /> have prepared this,applicatjon and that the work,will berdone in accordance with San Joaquin county ordinances, state laws, and + <br /> r. ruses and regulatioris;of,the San Joaquiy Local Health,District. } <br /> Nome owner or licenseagent's sigria"tura certifies-the following:�I certify that in the performance of the work for which this permit is issued, I shall not ^1 <br /> employ any person insucFi manner 9s to become subject to.workmaWs compensation laws of California." Contractor's hiring or sub-contracting signature <br /> E certifies the following_ "I ceTrtifysthat in the perfo�ante of the work for:which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.'; <br /> 4 <br /> f The applicant t<a !require ions. Complete drawing on-reverse e �JA <br /> ` Signed ` Title: Date: <br /> NI� `' mak :✓ <br /> FOR-DEPARTMENT USE ONLY <br /> ell <br /> Application Acceptedbyw �t �` � <br /> Date Area <br /> 1 Pit or Grout Inspection by Date T Final Inspection by • Date D <br /> `"A�ditional'Comments:-i "+ Y 5 +� - <br /> f ❑ Stk 466 8781 ❑ Lodi 369-3621 ❑ Manteca 823-7104` ❑ Tracy 835-6385 <br /> - Applicant Return all copies «Ern iroFiFti l Health Permit/Services-1601:E: Hazelion AVe., P.O. Box 2009, 5tk., CA 95201FEE <br /> f <br /> I <br /> t INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED 13Y DATE PERMIT'NO. <br /> i R 1 <br /> +.EH-13-24(REV. /H 5) <br /> `. <br /> EH-14-11 <br />