Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—1 ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED <br /> (Complete in Triplicate) <br /> /or install the work <br /> .This <br /> cation is <br /> t to <br /> Application is hereby made to the San Joaquin Local He No District49 for sewage or+No:1862 forcwellldpump and the Rules and(Regulations of the San+Joaquin i <br /> made in compliance with San Joaquin County ordinance + <br /> Local Health District. yr r <br /> y W 8 �—f 1� City � <br /> Lot Size PM <br /> Job Address 'C'.Phone <br /> E[.p Address <br /> Owner's Name <br /> � L'scense,No�9Q Phare <br /> � ��� Address <br /> ; <br /> Contractor {�aWELL REPLAGEMENT ❑ DESTRUCTION LJ <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR 'C] <br /> PUMP INSTALLATION E2SEWER LINES ��--- r P(TS1SUMPS <br /> 'DISPOSAL FLA. PROP. LINE <br /> DISTANCE 70 NEAREST: SEPTIC TANK —�— AGRICULTURE WELL OTHER WELL <br /> FOUNDATION �— — <br /> ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of-.Well Casing <br /> INTENDED USE TYPE OF W <br /> ~Da• of We <br /> Open-Bottom— "❑ Manteca -� ll Ezcavatian- <br /> ❑ <br /> ❑ IndusTraI F r Type of Casing Specifications <br /> El Domestic/ <br /> Tracy Domestic/Private ❑ Gravel Pack ❑ Delta <br /> Cl Other Depth of Grout Seal Type of Grout <br /> l'l Public Surface Seal Installed by <br /> t I Irrigation Approxi Depth i I Eastern State Work Done <br /> Type of Pump i H.P. <br /> Repair Work Done ❑ Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter <br /> Desivil <br /> pth_ _ Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATkON REI?AIRIADDETION.1 I DESTRUCTION i I availableiwthin 200 feet.) <br /> if public sewer is <br /> `Installation will serve: Resaaiderice_�. <br /> Commercial Other <br /> Number of living units: I 1 Number of bedrooms Water table depth <br /> i <br /> r Character of soil to a depth of-3.feet: ` Z � No. Compartments <br /> e/Mfg to�uC�Z�""'lr� Capacity��Y r— r, <br /> SEPTIC TANK a Typ ,. Method of Disposal <br /> { f .. . <br /> I PKG. TREATMENT PLT. T t �-r- � _ Property tine s <br /> Foundation <br /> Distance to nearest. Well t <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines 'f property Line <br /> FILTER BED ❑ Distance to nearest; Well <br /> Foundation <br /> # Number <br /> I SEEPAGE PITS I i Depth Size r.� oundat+o`n Property Line <br /> Folin at <br /> ( SUMPS ❑ Distance to nearest: Well t <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that i have prepared this application and that the work wilt be done..in.accordance with San Joaquin county•ordinances, state laws, and <br /> s permit is issu <br /> rules and regulations of the San Joaquin Local Health Di>;trict. work for <br /> Home owner or licensed agent's signature certifiesuti ec�lto wink man'srtaompensation laws Califorrn California." Contractor`sihir hiring or sub-contracting signature <br /> employ any person in such manner as to become 1 <br /> certifies the following.—,I certify that in the performance,of the work for which this permit isoissued, I shall employ persons subject t°workman's compens <br /> tion laws of Calif i .' <br /> licant call for all re d ions. Complete drawing <br /> The•app Date: <br /> Title: <br /> Signed X <br /> ` FOR EPARTMEN USE ONLY <br /> Date 4 Area <br /> r . Application Accepted by Dater - <br /> Date - -Final Inspection by <br /> a Pit or Grout Inspection by } )� <br /> Additional Comments: ❑ Tracy/835 6385 <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823 7104 [ u <br /> Applicant . Return all copies to: Environmental Health permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 \] <br /> I <br /> i FEE AMOUNT DUE AMOUNT REMITTED <br /> K RECEIVED BY DATE PERMIT'NO. <br /> I INFO <br /> r.EH 13-24(REV.t <br /> �� ✓ / 7 T <br /> EH-14-2e <br />