Laserfiche WebLink
' w <br /> APPLICATION FOR PERMIT + <br /> { SAN JOAQUIN LOCAL HEALTH DISTRICT v <br /> i� PERMIT N0. <br /> 1601 E. HAZELTON AVE., STOCKTON. CA <br /> Telephone (209) 466-6781 DATE ISSUED } •Z <br /> ,* PERMIT EXPIRES 1 YEAR FROM DATE• ISSUED <br /> � (Complete in Triplicate);t for a ermit to � <br /> l the <br /> Application is hereby made tothe Saen,Joaquin LocalwHeal h D3oaquin Countyp0 dinancecNa5t549tdforsewagesorlNo. 1862rf6rerein well/pump <br /> described. This application , <br /> ' n' complian <br /> and the Rules and Regulatio s 'of the San Joaquin Local District. <br /> ��x�� n <br /> Subdivision Name <br /> Jab Address Phone <br /> dress Phone <br /> Owner's Nam <br /> Contractor's Name <br /> License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL./ C>❑ WELL REPLACEMENT ❑ DESTRUCTION [] <br /> ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION DISPOSAL FLD. PROP. LINE � 1V <br /> DISTANCE TO NEAREST: SEPTIC TANK �f� SEWER LINES PITS/SUMPS <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL. <br /> _INTENDED SE TYPE:OF WELL PROBLEM AREA CONSTRUCTION SPECiFICATIO <br /> NS <br /> ❑Open Bottom ❑Manteca Dia. of Well Excavation <br /> Industrial Dia. of Well Casing <br /> ❑ Domestic/Private ❑Gravel Pack ❑Tracy <br /> Public Other ❑Delta Type of Casing <br /> ❑ Irrigation Approx. ❑Eastern Specifications <br /> Depth Depth of Grout Seal <br /> ❑Cathodic Protection 1 <br /> ❑Geophysical 1 Type of Grout <br /> U Other Surface Seal Installed by <br /> 1 Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> if <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 (No septic tank or seepage P°avai ableewithinu200cfeet) is <br /> Installation will serve: Residence Commercial _ Other <br /> Number of bedrooms Lot size <br /> Number of living units: �_. Water table depth <br /> Character of soil to a depth of 3 feet: S N a Capacity �"�d No. Compartments lZ <br /> SEPTIC TANK Type/Mfg C e wMethod of Disposal <br /> Capacity <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Foundation Property Line <br /> Distance to nearest: Well � <br /> / Total length/size Z y <br /> LEACHING LINE [ J No...&Length of lines(^X r2 _ Property Line <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> Depth Size Number , <br /> SEEPAGE PITS [J- De p — Proper-ty'Line, <br /> Distance to nearest: Well Foundation �-6— <br /> 1 SUMPS <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homejw;srior ssued,elsshallenotsemploytany person1en suchs the fmannernas to become subjectthat ntohworekman rfo§compensati1onwlaws fof California." <br /> perm <br /> Contractor's hiring ,5r sub-contracting ersonsusubject�toeworkman�slcampensationrlaws ofaCalifornit in the aerformance of the work for whit <br /> this permit is issued, I shall emp oy p <br /> The appl' ant must 1 all re ed inspe ions. Complete d �ng��re�ve side. Date- <br /> Title* <br /> Signed <br /> 0 DEP MENT USE ONLY Area Cp ❑ Stk 466-6781- <br /> plication Accepted by Cr ❑ Lodi 369-3621 <br /> Additional Comments: Date Manteca 823-7104 <br /> Pit or Grout Inspection by 835-6385 <br /> Date �1��Z Q Tracy <br /> Final Inspection byP.0. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental He th Permit/Services 1601 E. Hazelton Ave., <br /> PERMIT N0. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 1� <br /> INFO d <br /> M � � L---f <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> to_9F <br />