Laserfiche WebLink
APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1641 E. HAZEI,TON AVE, STOCKTON, CA <br />t� Telephone 1209) 466-8781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) � WR,, <br />Application is heiaby made to the San Joaquin Local Health District for a permit to conxtr rkscribed This application 1a <br />made In compliance with San Joaquin County Ordinance No 549 lot sawage or No 18&2 for and the Rules andlations of the San Joaquin <br />Loral Health D�stnct 1 � i9ag <br />Jab Address Al r` City Lot Sue L. 114 PM q• 100- <br />Owner's Name 5 E! t of «'S <br />Address _ Phone <br />Contractor.Tal�G�i� f Add ras$"�2 , nee No 55�979P„�4 <br />TYPE OF WELL/PUMP NEW WELL—0 WELL EPLACEMENT Cl DESTRUCTION Q <br />PUMP INSTALLATION ❑ SYST M^ YPAIR Q OTHER )QSCI! C3,05 -In (3) <br />DISTANCE TO NEAREST SEPTIC TANK �SEWER LINES -�4�..L..�. DISPOSAL FLD _ PROP LINE.9X_ <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS— <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �6❑ knduftnat <br />© Domasuelprivate <br />('I Public <br />I I lm0000n <br />Repair Work Done Q <br />Well Destruction 0 <br />0TYPF, OF S <br />❑ open Bottom ❑ Manteca Dta of Well Excavation 014 of Wall Casing <br />❑ Gravel Pack ❑ Tracy Type of Casing Speclrkations <br />n ovwf n Delta Depth of Grout Seal Type of Grout <br />2 Apprott Depth I I Eastern Surface Soul Installed tilt <br />Type of Pump -__ -. H P. State Wor a <br />Wel! DIArnetar Sealing Material flop 50'1 P 3 <br />Depth . _ -- _ F41er Material 19elow W'l -- - .w1 <br />VVUKK NEW INST <br />1 i REPAIR/AODITION I I DESTRUCTION i i (No snplie syslam perrrettud it public fewer Is <br />available within 200 Iaet 1 <br />Insraltsuon rail serve 1-teeldence — Commercial — Otlwr <br />Number of living units Number of bedrooms <br />Character al and to a depth of 3 feet Water table depth <br />SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments <br />PKQ TREATMENT PLT ❑ Method of Disposal <br />Distance to nearest WON Foundation . Property Una <br />LEACHING LINE <br />0 <br />No & Length of lines <br />Total length/ske <br />FILTER BED <br />© <br />Distance to neareat. Well <br />Foundatiort Propony Line <br />SEEPAGE PITS <br />I I <br />Depth Sue <br />Number <br />SUMPS <br />Ll <br />astance to nearest- Weil <br />Foundation Property Lina <br />DISPOSAL PONDS <br />❑ <br />I hereby Carufy that I have prepared this epPhc don and that the work wi11 be done to accordance With San Joeq yn county ordinances, nate lawn. and <br />rules and regulaltons of the San Joaquin Local Health i]Rtrkt. <br />Horne owner or licensed ■gent's signature certifies the lottowlne "1 certify that In the performance of the work for which this perrtxt is taws 1 shall not <br />employ any person in such manner as to become sublacf to workman's eompensauon laws of Calilorrua " Cantractoel hiring or Wb i�n signature <br />cartlfies the following "I cartity that in tM performance of the work. for which this parmit is issued, I shall employ person � L� `�� compansa <br />(ton laws of Callfalnla " <br />The applicant list coo for all rowed inspections. Complete drawing on tevorse sidle !* <br />Signed Title 5r, G Fl ktA%*-Q <br />er % 2. <br />[ <br />FOR DEPARTMENT USE Ote <br />NLY � G <br />Application Accepted byIE <br />-- ►'Z`�"�1.� �-� - - pate ^ KI a 5 .. Area <br />011 or Grout 4napectlon by Date Final Inspection by Date <br />Additional Comn%enla. <br />❑ Sik 400 8781 ❑ Lodi 368-3621 ❑ lAwleca 823-7101 ❑ Tracy 836 85 <br />Applicant - Return all toplss to: Environmental health Permit/S4rvkes 1601 E Haraltort Ave., P O. Box 2009`,�Sikt,/CA 95201 <br />Cr. <br />AAAOUNT DUE AM4U14T REIrtITT#p CASH RECEIVED t)Y DATE PFRMIT NO <br />