Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ! } <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I <br /> ! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicates <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 /> e "made in compliance with San Joaquin County Ordinance No. 549 for"sewag . 1862 for wall/pump and the Rules and Regulations of the San Joaquin <br /> Local _Health Distric <(/ <br /> .<Job Addre s City VaI1111,410i'Size PM <br /> Owner's Name - Address Phone <br /> Contractor %W Address Lic66 Nd <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IJK DESTRUCTION <br /> PUMP"INSTALLATION L9' SYSTEM REPAIR ❑ OTHER © 1 <br /> DISTANCE•TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD.' " PROP. LINE <br /> _ FOUNDATION• AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> F <br /> r <br /> INTENDED USE �TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI <br /> ❑ Industrial C1 Open Bottom " .❑ Manteca Dia. of Well Excavation/� �/ Dia. of Well Casing , <br /> tt [ pomestic/Private "F"�'.. I�ravel Pack ❑ Tracy Type of Casing 1 V0_ (r� • h60 ; Specifications <br /> F <br /> � } <br /> f ublic ,' ; n Other fel Delta Depth of Grout Seal Type of Grout _-_ I• <br /> I t;Irriganon d' ,. H,. .Approx, Depth I I Eastern Surface Seat Installed by jn A1r <br /> r i-Repair Work:bone L7- Type of Pump _:-_ H.P. , State Work Do a <br /> s� Destruction <br /> e 1 <br /> Well 1' •IX Well Diameter� Sealing Material (top 501 A j IVA PA. a ! <br /> Q Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCT'ON i I (No septic system permitted if public sewer is <br /> available-within 200 feet.) <br /> t I <br /> Installation will serve:" Residence_ Commercial' Other <br /> Number of living units: .. _i Number oPbedrooms <br /> ZYCharacter'of soli to a depth of 3 feet: Water table depth <br /> i } SEPTIC TANK *1° "❑ s Ty s/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ f ; .,"' Method of Disposal �. <br /> t k i Distance to nearest:: Well Foundation Property Line <br /> LEACHING LINE ❑ ` No. & Length of lines Total length/sizq <br /> t FILTER BED' " ;:j: ❑ Distance to nearest: Well Foundation Property Line 7 ! k <br /> SEEPAGE PITS i I i i Depth Size Number <br /> i 5U�NPS r El� Distance to nearest: Well_ Foundation Property Line <br /> 1 DISPOSAL PONDS ❑ 3 ( 1 <br /> • I hereby certify that I have prepared this application and that the work will be done in accordance with San county ordinances, state laws, and „l <br /> ... _�—.1 <br /> rules"and regutatio a San JoagLin Local Health Distract. <br /> t ? Home owner tcensed aa s signature certifies the fo wing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> j j' employ any rson in such ma ner as to bec a sub j to workman's compensation laws of California. Contractor's hiring or sub-contract i n ure �_ I <br /> t certifies ih following: 1 certif, at in the r a e of a work for which bj&,permit is issued, I shall em lo <br /> " p y persons subject to workman's compensa- <br /> " " tion laws f Califor <br /> t The appl cant s call requir t s e awing o sid <br /> "• i <br /> Signed ?( Title: Date: _. <br /> FO DEPARTMENT USE ONLY ' 1 <br /> g Application Accepted by Date --1Z�� Area ✓ L I� ! <br /> I ? <br /> Pit or Grout inspection'by Date " f $ t-tFinal Inspection by Date <br /> t Additional Comments: <br /> r, ❑ Stk 466 fi781, ❑ Lodi 369-3621, ❑ Manteca 823-7104 •.^ 0 Tra 635 <br /> Applicant:.-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 x I <br /> ;q. <br /> INFO FEE 0UNT DUE AMOUNT REMITTED CK CASH RECEIVED'BY DATE PERMIYNq. <br /> r EH 13-24IREV 1/xyi f •�`3� <br />