Laserfiche WebLink
APPLICATION FOR PERMIT <br /> a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephohe 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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 work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. / <br /> City <Ab r Lot Size i PM <br /> t Job Address /► /� �// /.� �+ <br /> C+A�iJt;J W, VIL~e Address {�' y- a CeCRl1� S Phone <br /> j Owner's Name <br /> ktlry �D$s Address ,` 7z� <br /> Contractor a ex 7 License No.37738f Phone y" <br /> TYPE OF,WELL/PUMP: NEW WELL 39 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION, SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -I4Z-- SEWER LINES DISPOSAL FLD- Io PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS ` <br /> ! Dia. of Well Excavation}� Dia. of Wel! Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 1,' E a <br /> i - .. . ttt Specifications - `AVS• <br /> �I <br /> Domestic/Private J Gravel Pack ❑ Tracy Type of Casing <br /> C+!hI�I�T <br /> n Other»� x`. Cl Delta Depth of Grout Seal---y Type of Grout <br /> f`l�Public' 14 _e <br /> 4 — <br /> I I lui"ation 'LQ�.Approx. Depth I i Eastern Surface Seal Installed by O <br /> f.: State Work Done_ <br /> Repair Work Done ❑ Type of Pump V ^ H.P."j <br /> WellrDesxruction ❑ WeI`0iameter_ • Sealind'Material (top 501 [� <br /> ( Dt pth Filler Material (Below 501 <br /> TYPE-OF SEPTIC WORK, NEW INSTALLATION l 1 - REPAIR/ADDITION l I DESTRUCTION I 1 lNo septic system permitted if public sewer is <br /> I t ti available within 200 feet'.) \ i <br /> s � 11V\7 <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units. Number of bedrooms <br /> Character of soil to adepth of 3 feet: Water table depth <br /> t, , <br /> SEPTIC TANK / ❑ Type/Mfg Capacity No. Compartments <br /> f 1 , �� Method of Disposal <br /> r PKG.`TREATf1AENT�PLT. ❑ � <br /> Distance to nearest: Wel! Foundation Property Line <br /> LEACHING LINE ENo. & Length ofnes Total length/size <br /> FILTER BED ❑ Dista cn e,t_o nearest. Well Foundation Property Line V a <br /> SEEPAGE PITS i I Depth 4' Size Number <br /> SUMPS ' Ll Distance•to nearest:` Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ ' <br /> I hereby cartify 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 tollov'in.w "",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`scompensation 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 mus all for aH r quired inspections. Complete drawing on reverse side. <br /> Signed X' � � Title: Date: S" -.v 4 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date��®`.Z2" Area <br /> Pit orro Inspection by ate L5 f Final Inspection by Date <br /> r. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> E ( FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NQ. <br /> I INFO <br /> +.EH13-24iREV.t/rs51 yo <br /> EH 14-26 1 <br />