Laserfiche WebLink
I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! <br /> (Complete in Triplicate) i <br /> I�cation is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is ' <br /> AppY <br /> elllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No- 18&2 for w <br /> Local Health District. <br /> �} Lot Size PM <br /> Q� <br /> Job Address City <br /> Phone (v <br /> Address <br /> Owner' <br /> Contractor <br /> Sp .C. Address J210 �x ISI License No._�_--PhO <br /> NEW WELL ❑ WELL REPLAC # <br /> SYSTEM REPAIR El <br /> EMENT ❑NEW <br /> ❑ <br /> Y� TYPE OF WELL/PUMP- ' OTHER El <br /> PUMP INSTA ❑ <br /> LLATION R <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS —t <br /> i FOUNDATION AGRICULTURE WELL ' <br /> INTENDED USE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -ia: of Wel! Casing f <br /> El industrial F1 Open Bo to LI Manteca Dia. of Well Excavation a <br /> Ing , Specifications <br /> F3 Domestic/Private ❑ Gravel Pack Type of Grout -_ <br /> I'I Public 171 <br /> Other elta of Grout Seal <br /> t I 1 Irrigation prox. Depth I I Eastern Surface Seal by <br /> Type Pstate one <br /> T _ <br /> Repair Work Done YP of Pump H.P. <br /> Sealing Material (top 50') <br /> Well Destruction - ❑ Well Diameter g _ I <br /> F Depth Filler Material (Below 50') T <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I ! DESTRUCTION- --availableJNo {wi hhiinn 20c system 0 fee dnie <br /> Installation will serve: 14,04 <br /> �[dlif public sewer is <br /> 4, Residence Commercial Other t /' ,0 4��d 0•T /� " , <br /> Number of living units: Number of bedrooms �1 <br /> Water table depth _ <br /> IF, Character of soil to a depth of 3 feet: <br /> SEPTIC TANK © Type/Mfg Capacity <br /> No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ I <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> Total length/size <br /> LEACHING LINE ❑ Na- & Length of lines -�r-r— -- <br /> El io'nearest=""Well"°" Foundation Property Line <br /> FILTER BED <br /> f <br /> SEEPAGE PITS I I Depth SizeNumber <br /> Property Line <br /> SUMPS Ll Distance It nearest: Well Foundation p rtY <br /> DISPOSAL PONDS ❑ <br /> r rk will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the wo <br /> rules and regulations of the San Joaquin Local Health DR trict. y <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 mariner as to become subject to workman's compensation laws of California." ploy cersons'ring or sub"ct to woorkman'rnsignature <br /> scompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ p 1 <br /> tion laws of California." <br /> The applicant st call r all r wired i ons. Complete drawing on�r vverse ide. <br /> Signed r <br /> Title: _ Date: . <br /> l FOR DEPARTMENT USE ONLY <br /> t <br /> Dab 0 Area <br /> te `� <br /> iApplication Accepted by r <br /> Pit or Grout Inspection by <br /> Date Final Inspection by ✓ Date <br /> -� <br /> [ Additional Comments: <br /> 171 Stk 466-6761 El Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 <br /> I 601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1 <br /> f <br /> ffE!A;MOEUNTCK RECEIVED BY DATE PERMIT'NO. <br /> UE AMOUNT REMITTED CASH �o 3S-0 U <br /> + EH 5324IHEV.i/ss7 - <br /> EH 14-2e <br />