Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> r Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> k (Complete in Triplicate) <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.54916r sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> AT Ci li�/V Lot Size�I�A�� PM <br /> Job Address City <br /> Owner's Name N d 0 AJ if ;dl Address .EAm E ew Ae d-s- Phone 9Sf <br /> Contractor's Name . �rJ61ild /ce License No. �1��+7�� s Phone -gur <br /> TYPE OF WELL/PUMP: NEW WELL EJWELL REPLACEMENT DESTRUCTION El <br /> PUMP INSTALLATION_P�, SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK! SEWER_LINES �� DISPOSAL FLD. _ PROP. LINE <br /> @ 1 FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 16 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W <br /> ❑ Industrial ® Open Bottom . ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack q ❑ Tracy Typeof Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout <br /> 4 <br /> Irrigation. --LApproz. De� ❑ Eastern - _ Surface Seal Installed by <br /> Repair Work Done $1 1l-ype of Pump - u JFH.P. ZY State Work Done <br /> Well Destruction ❑ Well Diameter %� Sealing Material [top 50`)µ ` <br /> Depth ��!)[7 Filler Material (Below 50') { <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 'j <br /> ' available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 1 4 Water table depth F <br /> SEPTIC TANK. I ❑ Type/Mfg j Capacity No. Compartments t <br /> PKG. TREATMENT PLT. ❑ Method of Disposal Z <br /> .Distance to nearest: 'Well" Foundation ---Property-Line­—­ <br /> LEACHING <br /> ine­—t."LEACHING LINE ( ❑ No. & Length of lines Total length/size <br /> FILTER BED 1 ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS ❑ Depth 1 Size Number <br /> SUMPS = t ❑ Distance to`nearest: Well Foundation Property Line <br /> DISPOSAL PONDS' ❑ M i <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 Ae , h manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifiesertify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compention lawThe appo all re uir spections. Complete drawing on rover-sdde. <br /> Signed Title: Date: <br /> r <br /> a FOR DEPARTMENT USE ONLY ? d <br /> Application Ac ed y Date Ah Area% ? <br /> -wee , <br /> pp 1 <br /> Pit o 2 +n i Date t� Final Inspection by Date <br /> Additional Comments: / <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621' i ❑ 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 95201 <br /> k <br /> FEE <br /> INFO ° AMOUNT DUE r AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> k <br /> �sv EH 13-24(REV.10193) it . - _ <br /> r'EH 1428 <br />