Laserfiche WebLink
�~ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON A\/ <br /> E., STOCKTON, CA .f <br /> Telephone (209) 466 6781 <br /> _PERMIT EXPIRES 1 YEAR FROM DATE 1 D <br /> (Complete in Triplicate) <br /> r <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 sewage or No. 1862 for weii/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Y �C, City Lot Size PM l <br /> Job Address / r <br /> Address 13Z - / Phone `6� <br /> Owner's Name M <br /> Contractord� ' S <br /> I AddreSs License No. Phone f -37-AQ ; <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 3 PUMP INSTALLATpION)W SYSTEM REPAIR ❑ OTHER ❑ �f <br /> 111 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISU L' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICf( <br /> ❑ Industrial t ❑ Open Bottom ❑ Manteca 7Dia. f Well Excavatio�E� <br /> Dia. of Well Casingof Casin`L ' 5peci#icatioras <br /> Domestic/Private Gravel Pack r ©-Tracy— <br /> Type-of <br /> 9 -- <br /> I [� Other '- C1 Delta Depth of Grout Seal � �Type of Grout <br /> (`1 Public <br /> I I Irrigation --Approx. Depth ( 1 Eastern Surface Seal Installed by- <br /> Repair Work Done ❑ Type of Pump <br /> H.P. _ State Work Done <br /> i Sealin Material (top 50'1 k <br /> Well Destruction ❑ Well Diameter g } i I <br /> 1 j Depth Filler Materiah(Below150') <br /> tic stem permitted if public sewer is O" <br /> TYPE OFSEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I'I DESTRUCTION I I (No sep. y I <br /> T 3 available within 200 feet.) , <br /> Installation will serve: Residence_ Commercial_ O'ther r i <br /> Numb&r_of Living units: Numb6r of bedrooms F� J- �-� -C I <br /> Water table depth <br /> Charact re of soil to a depth of 3 feet:." , <br /> Ga acity t No. Compartments <br /> SEPTIC TANK ❑ Type/Mfgf . <br /> Method of Disposal i <br /> PKG. TREATMENT PLT. ❑ <br /> 9T Distance to nearest: Well t Foundation Property Line <br /> IW �'Total length/size ! <br /> LEACHING LINE ❑ No. & Length of fines <br /> FILTER BED I. ❑ Distance to nearest: Well Foundation Property Line I <br /> I p <br /> SEEPAGE PITS R. � (11 Depth Size � Number <br /> SUMP 5 _ j ,� L1 Distance_to_nea'rest: Well Foundation Property Line �� � _ <br /> DISPOSAL PONDS � __-..-______._ <br /> I hereby certify_that-L.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 Dislrict � i �+. <br /> Home owner or�lice.nsed_agent_ssignature certifies the following_ "I certify that in.the..pe_rformance of t_h_e work for which this,Permit is issued, I shall not <br /> employ any person in such manner as to become subject to wbrkman's compensation laws of California. Contractor s hiring ar sub contracting signature <br /> I certifies[he 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 C-'alifornia." <br /> The applican I requir n s. Complete drawing on rse side. <br /> Signed X Title: <br /> -� Data: <br /> FOR DEPARTMENT US ONLY <br /> Application Accepted by <br /> Date Area 1 -21 <br /> Pit or Grou Inspection by Date O-4 _� Final Inspection by� ° r Date 9 <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant . Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CKj <br /> i FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NNOO. <br /> +.EH 13-241REV.1/951 ,i `LJ� QAI' �/`' Z <br /> EH 14-28 <br />