Laserfiche WebLink
"" APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> iCornplete in Triplicate) <br /> lth District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaquin Local Wea <br /> or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. / !/ � ) <br /> A (v'�Y' ��, � rtp,.✓G lw r City S7ocK7—�ot size PM <br /> Job Address <br /> fll <br /> Owner's Name �lZlVR�E�� 'jA7tdress Phone <br /> t <br /> Contractor <br /> Address a–o,c License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Dia. of Well Casing <br /> y Type of CasingSpecifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yP <br /> F] Public Ill Other Cl Delta Depth of Grout Seal Type of Grout — <br /> f Approx. Depth 4 I Eastern Surface Seal Installed by - <br /> I i Irrigation <br /> ►. H.P, I State Work Done _ <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50')' t� <br /> k Depth Filler Material (Below 50 �\ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> 1 available within 200 feet.) <br /> Installation will serve: Residence Commercial, Other y <br /> i Number of living units: Number of bedrooms ' <br /> I s <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. ❑ r Method of Disposal <br /> I <br /> Distance`to nearest: Well Foundation Property Line <br /> ` LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r FILTER BED ❑ Distance to nearest: }Well Foundation Property Line, <br /> i <br /> SEEPAGE PITS i I Depth # Size _ Number <br /> i <br /> SUMPS P Distance to nearest: i Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ; a <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 /> f' 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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor'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." I <br /> The:Ppllcant stcll far all reaquired inspections. Complete drawing on reverse side. . f <br /> ISignd X Title: >t�P�`. Date: <br /> f <br /> TMENT USE ONLY <br /> Application Accepted by C't"' Date �� � Area <br /> Data Final Inspection by Date 7 <br /> ' Pit or Grout Inspection by , <br /> d -1/-F. ��sa Z <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man eca 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 AMOUNT REMITTED CIC RECEIVED BY DATE PERMIT'NO. <br /> INF CASH <br /> // ' <br /> r.EH 13-24 IHEV.i/H 5Y I 00 ���+� • <br /> EH 14-25 <br />