Laserfiche WebLink
1 � i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED µ <br /> ri' s <br /> ") {Complete in Triplicate) <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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.:.. ,., >,y �.•..�. ,. L <br /> i[,. r.r- " . . zf„E�J1(� PN1_ <br /> 1 g� R �O►�C. , Clty, Lob Lot Size <br /> Job Address <br /> C13 /60 VO <br /> Owner's Name _ /T/] RrsIS Address. - Phone f, <br /> .Contractor's Name V '1 h *"L_icerfse_,NO_A,_Z �`� _ Phone 133 0 f <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM"REPAIR ❑ OTHER ❑ <br /> / f r <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD, 5 PROP. LINE- <br /> FOUNDATION . AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation I gX k Ilia. of Well Casing <br /> Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing_ S a Specifications <br /> Cl Public ❑ Other ❑ Delta Depth of Grout Seal S0 Type of Grout C� - <br /> r <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done '� Type of Pump SF=r H.P. State Work Done <br /> Well Destruction Well Diameter tri CIt Sealing Material (top 50'1 -�Y1LP lrt <br /> Depth a-O d 4� Filler Material'{Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence____ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK _ ❑ Type/Mfg_. ` Capacity_ _ No. Compartments <br /> PKG. TREATMENT PLT. F71 of Disposal ' <br /> Distance to nearest: Well Foundation"""'"" Property Line <br /> " �, -------Total len th/size 's G <br /> LEACHING LINE r ! ❑ No. & Length of lines g <br /> FILTER BED ❑ ,Distance to nearest: Well Foundation- ft _. - ` Property-Line <br /> SEEPAGE PITS ❑ Depth I Size �' Number <br /> SUMPS ❑ 'Distance to nears§t: Well -Foundation, — Property Line <br /> - r <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. S,;A <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of:the�work�for which this permit is issued, I shall nate <br /> employ any person in-such manner as to become subject to workman's compensation laws of California." Con'tractor'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." e <br /> The applicant t call for all requi a in ctions. Complete drawing on reverse skid-e. <br /> Signed Title: ��^�n Da-i,: <br /> e FOR nDEPART MENT 5E ONLY i <br /> Application Accepted by Date O y Afea <br /> Pit or Grout Inspection by l ate �i Final inspection by Date <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi -369-3621 + D Manteca 823-7104 -❑Tracy 835-6385 <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", MOUNT REMITTED RECEIVED 8Y DATE PERMIT"NO. <br /> CASH <br /> INFO ' <br /> Jam/ ,Q r <br /> +EH 13-24 MEV.101831 L <br /> EH 14-26 1 <br />