Laserfiche WebLink
+, APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work herein describe . <br /> is <br /> madlecnt1compliance weieby wiitth Sanade toJoaqu nthe San Coungty OrdinaJoauin nce No.549 for sewage or ealth District for a permit <br /> No. 1862 forcwe ildpump and the Rules and Regulations of tthe Sanapplication <br /> Joaquin <br /> Local Health District. <br /> / City *�+ Lot Size PM <br /> Job Address ' <br /> Owner's Name Address <br /> Phone <br /> DQ _7-0,0f—Address No <br /> Contractor Rr?r �fsi _ Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUM STALLATiON ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC T SEWER LINES AL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WEL OTMER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR M AREA NSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom — ❑ Monte Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack acy <br /> e of Casing Specifications <br /> fl Public ❑ Other ❑ Delta Depth Grout $ <br /> eal Type of Grout — <br /> I 1 Irrigation _..Appro epth I Eastern Surface Sea tailed by <br /> Repair Work Done ❑ Type o H.P. State Work Done <br /> I Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth Filler Materia! (Below 50') <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I I I REPAIR ADDITION DESTRUCTION I I (No septic systethin m permitted if public sewer is <br /> Installation will serve: Residence_ Commercial X_ Other O <br /> Number of living units: Number of bedrooms O <br /> Character of soil to a depth of 3 feet: L Water table depth <br /> SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Method of Disposal <br /> Distance to nearest: Well F ounoattiion Property Line f <br /> LEACHING LINE No. 11 Length of fines tP <br /> Tal length/size <br /> FILTER BED ❑ Distance to nearest: Well. Q... Foundation ! Property Line_ _ <br /> SEEPAGE PITS Depth -Size Number <br /> mber <br /> SUMPS 0 Distance to nearest: Well Aft*!! Foundation Property <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 /> i 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 follow!qt "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 Pawgk:"The appr ! spa C plate drawing on arse side <br /> Signed Title: Date: <br /> i <br /> FOR DEPARTMENT USE 0 LY g <br /> Application Accepted by <br /> Date �!�` ` Area <br /> Pit or Grout Inspection by Date final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> CK 9 ffi <br /> AMOUNT REMITTED CASHRECEIVED BY OATE PERMIT'NO.�j <br /> y +.EH 13.24(REV.t/n 5) _Q—�� <br /> EH 10-28 v <br />