Laserfiche WebLink
4 ` <br /> APPLICATION FOR PERMITS <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> _ 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone'{209) 466-6781 <br /> - #' . .^ £a: i I. � <br /> RES 1 YEAR FROM D <br /> PERMIT EXPIATE ISSUED n <br /> in-Triplicate): ,z <br /> 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.549forsewage or No. 1862 for.well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> ..110 <br /> Job Addre +her rf ,''' <br /> City Lot Size <br /> PM <br /> Owner's Name - - <br /> dress y �' .�.. - Phone � V <br /> Contractor _ Address r <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L7 <br /> PUMP INSTALLATION ❑ SYSTEM'REPAIR ❑ OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> I ili;,FOUNDATION DISPOSAL L PROP. LINE <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEMAREACONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Ll Domestic/ �\ <br /> Domestic/Private Q'-Gravel ❑ Tracy Pack Dia. of Well Casing <br /> Q Public ' y TYPe of Casing Specifications <br /> ❑ Other 11Delta Depth of Grout Seal <br /> ❑ Irrigation N Type of Grout <br /> t —Approx. Depth �--❑,Eastern -'-----Surface.SeaL.lnstalled by <br /> Repair Work Done ❑ Type of Pump f H.P. <br /> State Work Done 1C <br /> Well Destruction C1 Well Diameter Sealing Material (top 50'i � v` <br /> t Depth ` <br /> Filter Material (Below 50') 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ UCTION <br /> septic system permi <br /> —Atted if public sewer is <br /> Installation will serve: Residence Mable within 200 feet.) <br /> Commercial, Other <br /> Number of living units: _Number of bedrooms <br /> Character of soil to a depth of 3 fee <br /> SEPTIC TANK Water table depth' <br /> Type7Mfg� Capacity No. Compartments <br /> PKG. TREATMENT PLT. Q ?} "`� "'' <br /> Method of Disposal <br /> Distance to nearest: WellFoundatiori Property Line <br /> LEACHING LINE ❑' No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ .Distance to nearest: WellFoundation <br /> `Property Line <br /> I _ <br /> SEEPAGE PITS ❑ Depth' Size <br /> Number <br /> SUMPS ❑ Distance to nearest:-- WellProperty Line <br /> Foundation <br /> DISPOSAL PONDS ❑ <br /> 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 licensea 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 must call for all re ire inspections. Complete drawing on reverse side. <br /> Signe( Title: ~1 P'� f <br /> — Date: _. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by i F <br /> Date Area <br /> Pit or Grout Inspection Date Final Inspection by ' /f- <br /> Date <br /> Additional Comments: �� { <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca. 823-7104 Tracy 835-6365 <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 <br /> INFO AS RECEIVED BY DATE PERMIT NO. ` <br /> + EH 13-24(REV +i H a l �'�. © 2OD ,0 /'7—C-,l 6--7 P7[// �I <br />