Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN .fOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 5 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I'YEAR FROM DATE ISSUED <br /> (Complete'in Triplicate) <br /> . This <br /> cation is <br /> Application is hereby made to the San Joaquin Ordinance <br /> Health Dis549 <br /> trict for a for sewagepermit <br /> No. 1862 forcwellld/orinstall the work pump and the Rules and(Regulations of he Sang Joaquin <br /> made in compliance with San Joaquin County Ordinance No.54 9 � <br /> Local Health District. ' <br /> Lot Size /409 9 PM <br /> Job Address <br /> t Phone ^ <br /> Owner's Name �a-W1 h7.1 GZ Is. — Address <br /> ..Phone <br /> """"'"""rAddiess Licari§e Na:.�-- <br /> -- <br /> Contractor 7"�'•DE57RUC7lON ❑ I <br /> . YPE OF -:Sa <br /> WELL/PUMP: -.NEW WELL LJ WELL REPLACEMENT ❑ f :+ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR I] ,� OTHER ❑ <br /> -"-- p1SPOSAL FLD PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER WELL MPS <br /> nr F' <br /> FOL(N D ATI ilE 4 <br /> r T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU ft' ECIFIGATIONS pia. of Well-Casing <br /> -. - _. <br /> ❑Industrial ❑ Open Bottom ❑ Manteca of Well Excavation <br /> T e of Gasiri -»..-specifications <br /> Q DomesticIPrivate Q Gravel Pack ❑ T "' YP g Type of Grout - <br /> f'} Public n Other�Depth <br /> C1 Delta IDepth of Grout Seal '�-I Irrigation i i Eastern # Surface Seal installed by I \ <br /> Repair Work Done ❑ pe of Pump H.P. <br /> State Work Done ! <br /> F Well Destruction ❑ Welt Diameter Sealing Material (top 501 Y <br /> ` Depth It Filler Material (Below 50') <br /> r perm <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIWADDITiON Ll DESTRUCTION I (Noavasbetic syst m feet.) <br /> if public sewer is <br /> Installation will serve: Residence— Commercial�' Other <br /> 1 <br /> fr <br /> Number of living units: Number of bedrooms + 1 <br /> i I Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments. <br /> t Capacity <br /> SEPTIC TANK ❑ Type/Mfg { Method of Disposal" ' <br /> PKG. TREATMENT PLT. ❑ <br /> pa Property Line <br /> { Distance to nearest: Well � Foundation � <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines _ E <br /> ❑ Distanc;to nearest: Well Foundation Property Line <br /> I FILTER BED 1 ' <br /> ♦ Number <br /> „[ SEEPAGE-PITS--- ` [•il 1.t�ept Size <br /> SUMPS ^"yL� Distahi eF to nearest: Wel! Foundation Property Line <br /> t <br /> DISPOSAL PONDS M <br /> I hereby certify that 1 have prepared this application.and that-the work will be_done,in-accordance.with,5an-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 cenjfies the_following:,Ll certify that.in thaaperfor_mance,nt the work.for.which,this permit is issued, I shall not.., <br /> arson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring o sub-contracting signature <br /> employ any p arsons subject to workman's compansa- <br /> r certifies the following: "I certify that i n,the performance of the work for which this permit is issued, I shall employ p; s + I t <br /> tion laws <br /> int <br /> Galifornia." i The appli st c fo a ed nspactions. Complete drawing on reverseside.Title:-,_,-Signed,X - � Y <br /> FOR DEPARTMENT.USE ONLY / <br /> Date Area <br /> Application Accepted by r <br /> LI Data Final Inspection by Date ? I <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> 4/,7W' A33*- ?!f-V <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 635 6385 <br /> r Applicant- Return all copies to: Environmental Health Petmit/Services 1601•E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I FEE CK RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> I + EH 13-24 MEV.t/n 51 J ' 991�'0 M.�- - <br /> EH 14-26 <br />