Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA ,} <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i .THsinall the work <br /> descr <br /> here <br /> Application is hereby made to the <br /> County Ordinance Health <br /> D5 s trict for sewage or for a perINo. 1&62 forcwell/ is <br /> dpump end the Rules and IR gulations of he Sanl cation Joaquin 4 <br /> made in compliance with San Joaquin <br /> Local Health District. L4 IJ (4 ' <br /> E� AN Cny`�1 cCfKT� Lot Size PM <br /> Job Address © p�r� <br /> Phone <br /> Owner's Name ��� � f Address — <br /> T7, �f.� 1.2 a W 1�CGr O h License.No. / Phone �3 y 3-2 a <br /> Q.Cie AIA Al S W I,} N! Address <br /> C ntactor <br /> NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION 15TYPE OF WELL/PUMP: 1 OTHER ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _�- SEWER LINES PITS/SUMPS <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL <br /> • <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> E3 Industrial S <br /> El Bottom ❑ Manteca of Well Excavation <br /> ca — Dia. Specifications <br /> Type of Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> ED Public [I Other El Delta <br /> ��pprox. Depth ❑ Eastern Surface Seal Installed by AA <br /> ❑ Irrigation �+, <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> I <br /> Sealing Material (tap 50'1 <br /> ( Well Destruction F1 . Well Diameter Filler Material (Below 50'1 <br /> II Depth u! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ alvailabpelwi hisysn 200 feet.) <br /> ed if public sewer is <br /> s <br /> Installation will serve: , Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth U� <br /> Character of soil to a depth of 3 feet: Capacity— No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg — <br /> Method of Disposal —� <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> r � <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line <br /> f <br /> FILTER BED C1 Distance to nearest: Well <br /> t s❑ Depth Size Number <br /> 1 SEEPAGE PITS p Foundation Property Line <br /> SUMPS +❑ - Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> 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 /> 7hereby <br /> rules and regulations of the San Joaquin Local Health District. <br /> g this permit is issued, <br /> I Home owner or le rlssuch mannerastorbecome subject Ito wlorkman'srtcompensation Iify that in the awsoof Califorrnia." Cont actor'slhiri g or sub-contracting lsignature <br /> shall o <br /> employ any person <br /> cert"rfies 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 /> l The applicant t call f re iced inspections. Complete drawing on reverse s <br /> j Title: Date: <br /> Signed t <br /> . 0� <br /> FOR DEPARTMENT USE ONLY 3� <br /> + Date Area <br /> ! Application Accepted by 8 y fllXbJ-, <br /> Pit or Grout Inspection-by•w Date — <br /> Final inspection by Date <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy' !35 <br /> ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,AvePw0. Box 2009. Stk., CA 95201 f <br /> CK RECEIVED BY DATE PERMIT'N0. <br /> f N AMOUNT DUE AMOUNT REMITTED <br /> ICASH <br /> �5 ss 9x+s <br /> I + EH 13-24(REV.1/85) ` <br /> { EH 14-26 <br />