Laserfiche WebLink
i <br /> APPLICATION FOR PERMIT � <br /> w .. SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> I 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED- <br />' (Complete in Triplicate) <br /> t and/or install the work <br /> n described. This <br /> cation is <br /> Applications Vance with e to the San Jo Joaquin Coungty Ouin Ldinalncfe No.549 for sewage or ealth District for a permit <br /> No 1862 for cwelUpump and the Rules and IR Regulations of the San l Joaquin <br /> made in compliance <br /> Local Health District. <br /> i \� �'+ City ^kJ�1 Lot Size PM <br /> Job Address _ /p► T' �{h�y� �4] _ <br /> J Phone <br /> Owner's Name <br /> a <br /> Contractor - <br /> Adrdress License No. 1311one <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> OTHER ❑ <br /> PUMP INSTALLATION L] SYSTEM REPAIR Ll <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 Dia of Well Casing <br /> D Industrial L) Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ' Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout_. <br /> l l Public f_1 Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation —..Approx, Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work'Oane <br /> Well Destruction ❑ Well Diameter Sealing Material stop 501 <br /> Depth & Filler Material (Below 50') �— <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION i I DESTRUCTION i I (Nosbptic systithinem <br /> rmiitted if public sewer is <br /> avaeet <br /> r 1 <br /> Installation will serve: Residence_ Commercial_ Other <br /> f Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> I Method of bisposal \ <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I >7 <br /> t ! SiNumber <br /> SEEPAGE PITS I 1 Depth -Size — ^^� <br /> SUMPS 11 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 Di1trict. <br /> t 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 /> r 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." <br /> The appfi n must 11 for al aired i`ns_pg'ctions. Complete drawing o reverse side. <br /> _ \11111 Title: Date: <br /> Signed X - <br /> FOR DEPARTMENT USE ONLY c� <br /> Date <br /> l Application Accepted by <br /> ion !fy mac "" _` 4 Date <br /> Final inspect <br /> Pit or Grout Inspection by Date �,/ ' ,- ` ' <br /> f V <br /> Additional Comments: <br /> 11Stk 466-6781 El Lodi 369-3621 ❑ Manteca 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 55201 <br /> FEE AMOUNT DUE,,- AMOUNT REMITTED RECEIVED BY DATE <br /> ZT NO. <br /> 4. INFO <br /> ♦ EH 1324 tFIEV.t i x 51 '� Y <br /> EH 14-2e <br />