Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , 6fZS T I`/ l� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6761 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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*swage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job <br /> ,�/ j� ,J / <br /> Job Address 'Ty-/ l /V- r" lzl//7C.f1Z� City ,-% C-/C_ / Lot Size PM <br /> Owner's Name Address � � �I�. . : 0�-du��� Pion <br /> a++'Y- : {�fle0/v7C7 �i//S- 8�53L� Na✓.4'T� 5����oYoL �.�/ _ <br /> LLFUJSo/71 Address O4 �9iense No./�7l08/ Phone'77� �.7 r1 .�Z <br /> TYPE OF WELL/PUMP: NEW WELL' WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'W mon;— <br /> ATV-DISTANCE TO NEAREST: SEPTIC TANK SEWER.UNES DISPOSAL FLD. PROP. LINE _ 7a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _//. �' <br /> C4C 3 3'! �I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ufj-/,'t(sr /oc �q <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /A Dia. of Well Casing <br /> Ll Domesbc/Private 6 Gravel Pack ❑ Tracy Type of Casing -54 zP✓L Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal aO Type <br /> � a Grout <br /> a c <br /> ❑ Irrigation .�pproX. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done i t s <br /> Well Destruction ❑ Well Diameter ''Sealing Materiel(top 50•) <br /> Depth Fitly Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 ; .CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal <br /> Distance to nearest: Well Foundation Property line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> k FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> 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. <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 not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California."Contractors 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 mut II for all req uir i spections. Col to drawing on reverse side. <br /> Signed X Title:`'ey Lb C,/ST Date: <br /> %/Ty�f <br /> FOR DEPARTMENT USE ONLY <br /> j� <br /> Application Accepted�'b/T,4GrEt A✓.`'/lY/ C/ Date Area <br /> Pit or Grout Inspectiolfby Date Final Inspection by � ,p (.G� Date <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca SM-7104 ❑ Tracy 8366395 <br /> Applicant - Return a8 copies to:JEnvfronmennall Health Permit Moss 1 1 E.Ilazzehon A P.O. Box 2008, &k., CA 95201 <br /> FEE MOUNT DUE AMOUNT RE ITTED OK RECEIVED BY DATE PERMIT NO. <br /> INFO (� <br /> EH1}ar(REV.�•e51 <br /> EH S � 6 v \ 'Al le7-1L1 <br /> 1XN <br />