Laserfiche WebLink
r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 wof/ <br /> k hhe�e in described. This pplication 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 �"►-1� <br /> A e Jity ?QLot Size—Am PM <br /> Owner's NameAl— ( VA 1 ' Address i I/ MAO 14 L W Phone r <br /> ContractorV C � rvAddress m N N License No. �at � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL R LACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCETO NEARS SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom If Manteca Dia. of Well Excavation <br /> Dia. of Well Casing 1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 'V <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> i <br /> rrigation —.-Approx. Depth I } Eastern Surface Seal Installed by � <br /> Repair Work Done V_ Type of PumpM42&&_1 ' H.P. _. �]'S7 State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) 1 <br /> Depth Filler Material (Below 50') --��---- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION f I (No septic system permitted if public sewer is <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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant Yst call or all r uire inspections. Complete drawing on r rse side. <br /> i <br /> Signed X <br /> Title: <br /> FOR DEPARTMEN-If SE ONLY <br /> Application Accepted by 4 Date Area <br /> Pit or Grout Inspection b t _ <br /> Pe Y Date Fina Inspection by Date <br /> �Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tr cy 835-6385 <br /> \pplicant- Return all copies to: Environmental Health Permit/Services 1 E. Hazlton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �4 <br /> 4. FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATEPERMIT'N0. <br /> :r/H5, '70•fav 70. as 3sn 9-3 <br />