Laserfiche WebLink
Wim` <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601-E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby <br /> ance wmade <br /> ith San Joaquin County 0 di aLocal <br /> nce No.-District <br /> 549 for sewage or permit <br /> No.1862 for well//pump and the Rules and Regulat o�of the San Joaqu n <br /> i <br /> cation is <br /> made in comp ,. <br /> t. <br /> Local Health District. j <br /> I fiyr <br /> I sr /"Y���i City , PM <br /> E , Job Address _ y� Lot Size <br /> I k ✓� <br /> Address "Z�//a P Frc Cir/ch /�y� Pnone <br /> I � Owner's Name _ <br /> f4, o,Y /I0 `1*J�70 -:License No— �_/—Phone <br /> 4 Contractor- , X - i`SoN Address p <br /> TYPE OF,WELL/PUMP: NEW WELL O WELL REPLACEMENT El DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER C] <br /> PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FL-D._g <br /> t FOUNDATION AGRICULTURE WELL r- OTHER WELL PITS/SUMPS <br /> IIVTENDEQjUSE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> s ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> ❑ Other <br /> ' ; ❑ Delta W� Depth of Grout Seal yp x <br /> ❑ Public } <br /> O.Irrigation ---Approx. Depth El Eastern __5,u_rface Seal Installed by. r } <br /> t H.P. - State Work Done �•! <br /> �. Repair Work Done ❑ Type of Pump <br /> Sealing Material (top 50'I <br /> Well Destruction ❑ Well Diameter g <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION C] DESTRUCTION ❑ availabNo lelwithin 200 feet.)tem if public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> I <br /> Number of living units: /i Number of bedrooms Y <br /> Num <br /> ( � ,� Water table depth ' .� <br /> I Character of soil to a depth of 3 feet: Na. Compartments <br /> K ❑ Type/Mfg�. <br /> SEPTIC TAN �" Cllr Capacity_d {b Method of Disposal f`Y <br /> PKG. TREATMENT PLT. ❑ 1 <br /> Distance to nearest: Well /049' Foundation /10 Property Line <br /> A -80 ` Total length/size 1 Ga <br /> t LEACHING LINE m T No. & Length of lines �p• Property Line <br /> FILTER BED 7-1Distanceto,nearest: Well I0O Foundation P rtl' <br /> "•�' y � Number_ <br /> SEEPAGE PITS 0 Depth; Size <br /> t SUMPS <br /> istance to nearest: Wells Foundation Property Line <br /> N DISPOSAL PONDS ❑ <br /> i { I hereby certify that I have prepared this application and that the work will be done in'accodance with San Joaquin county ordinances, state laws, and <br /> f 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 /> 4 employ any person in such manner as to become subject to workman's compahsation laws of California."Contractors hiring or sub-contracting signature <br /> ifies the following:'9 certify that in the performance of the work for which this perm is issued,I shall employ persons subject to workman's compensa <br /> cert <br /> tion laws of CMifomia j <br /> The app;7;rze. <br /> all for�required inspections. Complete drawing on reverse side. <br /> I. I Title: Date: <br /> 1 Signed <br /> 1' FOR DEPARTMENT USE ONLY A— IAre <br /> Date a D <br /> Application Accepted by <br /> . Pit or Grout Inspection by <br /> Date Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> P Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 CK <br /> RECEIVED BY DATE PERMIT'NO. <br /> 1 r <br /> IFEENFO <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-24IREV.-1/851 <br /> EH 14-28 _. - <br />