Laserfiche WebLink
1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 5 <br /> 1601 E. HAZELT ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 .� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'' <br /> (Complete in Triplicate) h �... �. <br /> Local Health <br /> District <br /> far sewage or it to of 1862 for wellapump and he Rules and/or install the work construct (Regulations he SanJoaquin <br /> application.This <br /> Application is hereby made to the San Joaquin <br /> made in compliance with San Joaquin County Ordinance <br /> Local Health District. <br /> Job Address t. <br /> 3 City Lot Size PM <br /> Owner's Name <br /> �. Address � c Phone - <br /> (,r f License No. ,� Phone <br /> Contractor + }� Address <br /> TYPE OF WELLIPUMP. NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR Ll OTHER ❑- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROF'�Elhi't"""�' <br /> — -FOUNDATION -�' AGRICULTURE-WELL OTHER WELL PITS/SUMPS <br /> 7r <br /> t; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial E3 Open Bottom -1 Manteca Dia. of Well Excavation Specifications <br /> ❑ DomesticlPrivate ❑ Gravel Pack 17 T- Type of Casing <br /> k6 ` 1 T e of Grout <br /> 4 ❑ Public ❑ Other # ❑f'Delta 1 Depth of Grout.Seal ; yp ; <br /> F1 Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by l <br /> I <br /> H P State Work Done <br /> Repair Work Done Ll Type of Pump s <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 <br /> -Qepth - -�- ----Filler Material..(.Below 50-f-- <br /> m perm <br /> TYPE OF•SEPTIC WORK: NEW INSTALLATION r REPAIR/ADDITION ❑ •DESTRUCTION 1: avalableseptic <br /> wi h ne200 feet'ttd if public sewer is <br /> Installation will_serve:,Residence..a--"-Gwnrnercial,Other---- <br /> f . <br /> Number of living units: Number of bedrooms _l o -� t de t <br /> ;_ Water table <br /> p <br /> Character of soil to a depth of 3 feet. ta�j ap No. Compartments I <br /> SEPTIC TANK E: Type/Mfg !R 4- Capacity <br /> _ t� -�'�� Method of�E3isposal I <br /> PKG. TREATMENT PLT. 7-1 � �r ""' ` <br /> Distance to nearest: Well Foundat ons 00— <br /> Property Line�—i. 147 <br /> .� <br /> I .. "IT� <br /> �/ No. & Length-of-lines rr " T Total length/size <br /> LEACHING LINE= Y�.,, ) s 3 G7" Property Line <br /> FILTER BEU�`' ❑ Distanct}to nearest: WeII_ Foundatiorf�_� <br /> Number <br /> (SEEPAGE PITS r ❑ Depth Size <br /> ❑ t <br /> • Distance a_nearest: Well Foundation_ Property Line_ <br /> r SUMPS - { <br /> l DISPOSAL PONDS ❑ ' <br /> -3I hereby certify that I have prepared thisrapplication and that the work will be done in accordahce with San Joaquin county or nances, state laws, and <br /> fir <br /> ( <br /> rules and regulations of the San Joaquin��ceobal Health District. <br /> Home owner or licensed agent's signature rtifies the following: ' certify that in the performance of the work for which this permit is issued, I shall not <br /> t '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:"1 certify that in the perforr rice,of the work for which this permit is issued,f shall employ persons subject to workman's compensa <br /> tion laws of California." V --- <br /> fThe applicant must call all ired inspect( no s. Complete drawing an reverse side. <br /> (�/. <br /> (Signed ` ? Title: �-='''� Date: <br /> FOR DEPARTMENT USE ONLY <br /> .._ a <br /> Application Accepted by �A <br /> ----.~~.-=Date ++ Are <br /> 17 <br /> + <br /> Date <br /> !Pit or Grout Inspection by <br /> Date Final Inspection by <br /> r.: <br /> + 3 <br /> Additional Comments. 1 <br /> ❑ ❑ Lodi 369-3621 ❑ Manteca 823-7104 E3 Tracy 835-6385 <br /> A PPlicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box {2009, Stk., CA 95201 <br /> Stk 466 6781 <br /> FEE AMOUNT DUE AMOUNT REEJ— <br /> ,CSS .-. . RECEIYtvq-BY. y. i3ATE^--� '� PERMIT'N0.INFO_ ^-�"•'_" "__"'� �.n_ <br /> + EH 13-241REY.1/a5) <br /> EH 14-26 �' <br />