Laserfiche WebLink
APPLICATION;FOR PERMIT _ 21994 <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.:HAZEL T ON AVE., STOCKTON, CA SAN 10)%-Q1J1N LOCAL <br /> Telephone (209) 466-6781 Y. .� H ,TH 01STR1CT, F <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I <br /> uin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaq <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/Pump and <br /> hee R�yoo <br /> anddRe ut ns of the San Joaquin <br /> Local Health District. r. .'_t a V7 %7}�, <br /> Job Address t` ; `\ S <br /> City/oc < �dt6ize }. PM <br /> Phon <br /> Owner's Name 1 ddress <br /> 1rs /�i r� <br /> *WS-- 1-3 V7 <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION C3 <br /> PUMP INSTALLATION �� SYSTEM REPAIR ❑ OTHER Ll <br /> Al '� SEWER LINES DISPOSAL FLD. PROP. LINE , <br /> DISTANCE TO NEAREST: SEPTIC TANK ��� <br /> AGRICULTURE WELLOTHER WELL •PITS/SUMPS <br /> FOU N DATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> ❑ Industrial Pompe '`. . <br /> Specifications . <br /> JJoDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing – – c �f 1. <br /> ❑ Public ❑ Other El Delta - Depth of Grout Seal <br /> Type of Grout 11 <br />€ ❑ Irrigation <br /> (JACApprox. Depth ❑ Eastern Surface Seal Installed by AA <br /> Repair Work Done (:1 Type of Pump SL4_* H-P: State Work Done *t} <br /> Well Destruction ❑ Weil Diameter Sealing Material hop 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic sy tem permitted if public sewer <br /> is <br /> Installation will serve: Residence�A Commercial Other J ' <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: I <br /> I Capacity No. Compartments <br /> SEPTIC TANK El Type/Mfg <br /> t Method of Disposal <br /> --PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> 1 LEACHING LINE ❑ No. & Length of lines Total length/size <br /> 1 <br /> r FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` <br /> Number <br /> SEEPAGE PITS ❑ Depth ' ' Size <br /> �F <br /> SUMPS ❑ Distance to nearest:. WellFoundation - = Property Line-- Y- <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 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- y <br /> tion-laws of California." o <br /> The applicant must call for all required ins ons. Complete drawing on reverse side. <br /> Signed Title <br /> Date: ` <br /> FOR DEPA IVIENT USE ONIUM, „ /0- 7Date <br /> /l/ <br /> Application Accepted by 7:: _ <br /> i Pito Gro Inspection by — Date Final Inspection by bate{ <br /> Additional Comments: <br /> ❑ Stk 466-87$1 El Lodi 369-3621 ❑ Manteca 823-7104 C] Tracy 6315 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 CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO .%_J : <br /> + EH 1324(REV.101831 Z>C> <br /> EH 14-28 - - i <br />