Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL.i ON STOC . GA <br /> Telephone 209) 466-6781 <br /> PERMIT EXPIRES 1 YE <br /> DATE ISSUED I <br /> (Complete in Triplicate) <br /> all the work <br /> cation is <br /> Application is hereby made to the San Joaquin LocalnHealth District for a ce No.549 for sewage or permitto <br /> 1$62 forcwell/dpuomp atnd the Runes and rRegulations of he San n described. TNs l Joaquin <br /> made in compliance with San Joaquin County Ord <br /> ocal Health District. <br /> �d� Lot Size <br /> drPM <br /> City , <br /> r Job Adess c L/j 7" <br /> (,Al 60 �U Phone a/7 f <br /> Owner's Nam f ^;' <br /> Address <br /> License No.__—-�Phone <br /> _ _ <br /> Contractor WE REPLACEMENT El DESTRUCTION ❑ T <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER 171PUMP INSTALLATION 13 DISPOSAL <br /> REPAIR ❑ <br /> SEWER LIN 5 �—�-- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL pITSISUMPS <br /> FOUNDATION AGRICULT RE WELL <br /> INTENDED USE TYPE OF WELL P EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Mantec Dia. of Well Excavation <br /> I ❑ Industrial of Casing Specifications <br /> ❑ <br /> Domestic/ ❑ ❑ Tracy ,..Type of Grout–Gravel Pack Depth o out Seal n <br /> 5 Other Cl Delta <br /> i l Public Surface Seal I t I�red by <br /> '+ I 1 Irrigation —.-Approx. Depth t I Eastern \. State Work Done _ <br /> i <br /> Repair Work Done El Type Type of Pump ng Material atop.50'! i n <br /> Well Destruction C] Heali <br /> Weil Diameter �— SealiFiller ng <br /> (Below <br /> Depth <br /> vailab within 200 feet.) <br /> 3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIDN i.l E TRUCTION No septi system permitted if public sewer is <br /> r Installation will serve: Residence Commercial._ Other.�. � <br /> I <br /> i <br /> Number of living units: Number of bedrooms r Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> 1l T e/Mfg 'Capacity— <br /> SEPTIC TANK Type/Mfg 4 Method of Disposal <br /> PKG. TREATMENT PLT. ❑; 8 <br /> � ! Distance to nearest: Well <br /> Foundation Property Line <br /> ¢I. <br /> Total lengthlsize <br /> LEACHING LINE CI No. & Length of lines property Line <br /> i E) Distance to nearest: Well Foundation p y <br /> FILTER BED <br /> 1Size Number <br /> I. SEEPAGE PITS lit Depth Foundation Property Line <br /> i <br /> SUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS <br /> r i 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.gs permit is issued, I shall work for <br /> Home owner r on in such mannerastorbecome subject to wiorkman'srtify that in the compensation lawsofCaliforn California." Contractor'srhir hiring or sub-contracting signature o <br /> employ any person <br /> certifies the following: "1 certify that in the perfofmance 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 required inspections. Complete drawing on reverse s�/f <br /> � Date: <br /> vJ� Title: <br /> Signed X� <br /> FOR DEPARTMENT USE ONLY ��77 <br /> date v� Area <br /> Application Accepted by: A ate <br /> Date Frspection b <br /> Pit or Grout Inspection by <br /> �� <br /> Additional Comments: <br /> Manteca 823 7104 ❑ Tracy 935-6385 <br /> P <br /> El Stk 466-6761 n Lodi 369-3621 ., p.-0. Box 2{)05, Stk., CA 95201 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave <br /> K REC VED BY DA.E PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH <br /> INFO <br /> ♦ <br /> EH 1324 IREV.i/h 5Y 3✓`/ <br /> 3 �` <br /> EH 14-28 <br />