Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN .IOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> App:.cetion c hereby made to the San Joadum Local Health District for a permit to construct and/or,"tall the work herein described. This application is <br /> made in compkance with San Joaquin GwnN 0-dmance'Jo.549 for"wage or No •0162 for well/pump erne the Rubs ant Rekvlatioms of the San Jostluln <br /> Local Health District <br /> Job Address � City Lot r <br /> ✓ PM <br /> Owner's Names Address Phone <br /> Contractor _) Wil' Address,(-3S2/ �'/�r '��i LrcemeNo. 7CSo 4 Phone - 1 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT O DESTRUCTION LI <br /> PUMP INSTALLATION F-� SYSTEM REPAIR L1 OTHER ❑ '^ <br /> DISTANCE TO NEAREST: SEPTIC TANK _o`�IQ(�� SEWER LINES DISPOSAL FLD.":27p11110P. LINE r� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /11 <br /> I <br /> Ll IM/u..�al C Open Bottom LI Manteca Din. of Well Excavation _ Da. or Wait Casing <br /> G '� <br /> i+'Dorneetrc/Prvste L�Pack Ll Tracy Type of Casing Pl'or /G O Spec.1"hom <br /> ('I Puhlrc F1 Other Il Delta Depth of Gran Seat ......— Type of ran <br /> 111"..Wtoo _ApT,rot. Depth IIII Eastern Surff <br /> 7Seal Insulted by <br /> Repair Work Dome I3 Type or Pump ? r M.P.J /; State Work Lorre_ <br /> Well Destruction [1 Web Diarn.ter x.ling Moteru'Itop 50'1 _— <br /> Depth_ Filler Material r3elow 50'1 <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIRIADOITIO4 1 1 DESTRUCTION I I INo septic system permuted d Prrbkc s wa n <br /> ava4abb with"200 lset.l <br /> Instanaton will serve: Residence__ Commercial_ Other <br /> Number of Irving units: _ Number of bedrooms <br /> Character of sort to a depth of 3 feet: Water table depth <br /> SEPTIC TANK fl Type/Mfg Capacity _ No. Compartments <br /> PKG. TREATMENT PLT.f I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE I I No. A Length of lines _ ___ Total length/sire—__ <br /> FILTER BED I 1 Distance to rreares• Wap Foundation _ Property Lira <br /> SEEPAGE PITS I I Depth __ Sia Numbart <br /> SUMPS I : Distance to nearest Wap_ Foundation Property Line <br /> DISPOSAL. PONDS I I <br /> I harep,candy that I he.prepared this application and that the work will be done in accordance with San Joaqulr county ordrtuncas, stats laws. aro <br /> rubs and regularions of the San Joaquin Local Health District. <br /> Home owner or licensed"nt'a l gnature certifies the following: -1 conify that in the performance o1 the work for which this permit is issued, 1 shnil not <br /> employ any person in such manner as to biotome wblect to workman s compensation laws of Caldorn.a."Contractor's hiring w wR<omracting ognatua <br /> cemfies the following. "I cemfy that in the performance of the work for which this Permit is issued,I Mall employ persons subject to workman's com"ou <br /> tion taws cl California. <br /> The appl,cant m,u/tt Gere for all reqire <br /> ud .nspecfImw. <br /> f Complete drang on reverse side. <br /> Signed X � ''L?? Tine: 4—Lcr.-�—� .. Data: __-L' �/�77 <br /> R DEPARTMENT USE ONLY <br /> 2 <br /> Application Accepted by Date Aru / <br /> Pit or Grout Inatraaio Dan_ Final ImpKtMn leis �Lr�' -- Daa � <br /> Additional Comments- <br /> Sik 4666781 El Lod. 3693621 ❑ Manteca 823-7104 ❑ Tracy 835-6785 <br /> , .__. ,.__.-_ ___,__._. -_._....._i..__..1 ------- no. Alta C•k Pa ac7A1 <br />