Laserfiche WebLink
20 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA h <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> ation is <br /> . This <br /> Appliation <br /> compliance writhdSanoJoaquin CountyOrdinathe SaJoaquin lHealh District for a nce Nto. 549 for sewage or permit <br /> No. 1862 for well pump and the Rules and IR Regulations of he San Joaquin <br /> Local Health District. d <br /> D2— ! /V r' �� City /� Lot Size PM <br /> Job Address <br /> 2 Phone <br /> Address + <br /> Owner's Name <br /> of / V /��7f� /h 1_:9/LicLsnse No./ Phone } <br /> Contractor �/ U4af Add ss <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJDESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ®— OTHER ❑ <br /> DISTANCE TO !NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> t`l Public <br /> Other ❑ Delta Depth of Grout Seal Type of Grout j — <br /> I 1 Irrigation Approx. Depth�,,��I I Eastern Surface Seal Installed by r F <br /> p _sL�L — H.P. State Work Done <br /> Repair Work Done L3 Type of Pum <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material Itop 501 <br /> Depth Filler Material (Below 50'! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRJADDITION l I DESTRUCTION I I al o septicable system <br /> m emitted if public sewer is <br /> Installation will serve: Residence— Commercial , Other <br /> i Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foun ion Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: W Foundati Property Line <br /> ' SEEPAGE PITS I 1 Depth Size _ Nu er <br /> SUMPS E1 Distance to nearest: Well Foundation Property Line <br /> i DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin chanty ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local'Health Di?;trict. <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 becor6e subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fo Ing: certify that in the performa the work for which this permit is issued, i shall employ persons subject to workman's compensa- <br /> tion laws of alifornia." b <br /> The applic nt m st ca r all re rr om ete drawing oIFr e si <br /> Signed X Title: Date: �i ✓( J <br /> I OR DEPARTMENT USE ONLY <br /> � Date — Area <br /> Application Accepted by - <br /> f Pit or Grout Inspection by: <br /> ^""Date Final Inspection by Date�191 <br /> 4 Additional Comments:, <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> FEE AMOUNT REMITTED CW RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE CASH <br /> ..ate INFO 1 �f <br /> + EH t3 24(REV., H 5 �0 <br /> EH 14-2e <br />