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 1 YEAR FROM DATE ISSUED <br /> (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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address R ( 3 o /67C City IR 45, Lot Size �PG PM <br /> Owner's Name 1>11k 42S[Y Address 3 l 1 _;e�d S%C=1� P_J Phone <br /> Contractor's Name 4i,ZLicense 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 WELLF OTHER WELL PITS/SUMPS 1. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> ❑ Industrial ❑ Open Bottom- ❑ Manteca-`4,, Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack p Tracy" Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta �� Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth El Eastern SurFacei5"1'Installetl by r IJ <br /> r <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br />€ Depth Filler Material fgelow 501 W t � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONJ?r-tDESTRUCTION ❑ (No septic system-permitted if_p_ublblic_sewer is . .� , <br /> available wiihm 200 feet.h —�- <br /> .'Installation will serve: Residence ffff—'�Commercial Other- <br /> Number of living units: 4— Number'of bedro�otms _- ^_} `• <br /> Character of soil to a depth of 3 feet: GL�.a� '� e Water table depth Q <br /> SEPTIC TANK ❑ Type/Mfg4,' `Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal rta <br /> Distance to nearest: Well Foundation Property Line r <br /> i LEACHING LINE No. & Length of lines —_ 3 919 Total length/size ] <br /> FILTER BED ElDistance to nearest: Well� Foundation `moo Property Line <br /> r <br /> li <br /> SEEPAGE PITS ❑ Depth Size Numbers <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ;• <br /> 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." Contractors hiring or sub-contracting signature <br /> certifies the following:"I certifytharin the�rformance­of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> l The applicant must call for all quired inspections. Complete drawing on reverse side. <br /> Signed �_ _ �� � Title: 005 _f Date: 4f=.�l7` <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by _ Date 4 "� <br /> Area <br /> �- <br /> Pit or Grout Inspection by Date Final Inspection by r ' Date <br /> Additional Comments: �. <br /> ❑ Stk 466-6781 ❑ Lodi j369-3621 ❑ 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED '• CK# RECEIVED BY DATE PERMIT'NO• <br /> w r-� INFO `� CASH'' <br /> E .Eli 13-25(REV. <br /> 1426 10!831 <br /> EF1 <br />