Laserfiche WebLink
APPLICAT 8NFOR PERMIT ? <br /> C� �, SAN JOAQUIN LOCALHEALTHDISTRICT <br /> 1601 E. HAZEL T ON AVE.,.STOCKTON, CA <br /> Telephone(209) 466-6781 <br /> a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;x <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_4or well Ipump and the Rules and Regulations of the San..Joaquin <br /> Local Health District: �q <br /> QAC/ .Gity . C� ` 'Lot Size .7© G PM •, <br /> Job Address1—�� x _ <br /> { X,'�i/ %9 V �Addresa Ifs I19 Phone <br /> Owner's Namer�n�r_ _..,v-- _ <br /> Contractor Address 3t(1r}i -E—License No.527UC i7 -Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ?K.., DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �� ? <br /> INTENDEDUSETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u <br /> ❑ Industrial xl <br /> El Open Bottom 1-1MantecaDia. of Well Excavation Dia. of Wel! Casing ' <br /> ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_:�/ �� Specifications <br /> ❑ Public' ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> irrigation ' stalled by <br /> �W1 Approx. Depth Eastern Surface Seal In <br /> Repair Work Done JK Type of Pump H.P. /State Work Done <br /> Well Destruction .f � \Well Diameter Sealing Material (top 501 <br /> Depth +�! 'ti Filler Material (Below 50'] <br /> TYPE OF SEPTIC WORK:-NEW INSTALLATION ❑ -REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> # r:, available within 200 feet.) <br /> - Installation will sere: Residence= Commercial 3? Other °' ` r t <br /> � 1 <br /> Number of living units: Number of bedrooms <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK FIType/Mfg Capacity No- Compartments <br /> PKG. TREATMENT PLT. FIMethod'of Disposal ` <br /> Distance to nearest: Wel! Foundation Property Line , <br /> a ' Total length/size <br /> EV° <br /> LEACHING LIN ; ❑' No. & Length of lines , <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> '~ <br /> Number <br /> SEEPAGE PITS a,y�y ,.❑., Depth Size <br /> ' <br /> SUMPS t', 17Distance to nearest: Well Foundation Property Line <br /> } <br /> DISPOSAL PONDS ;9 ❑ <br /> that the work will be done in accordance with San Joaquin cou tty,o'rdinances, state laws, and <br /> 1 hereby certify that(`have prepared this application and <br /> rules and regulatio.ns,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 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 Califia" a <br /> ' The:ppli��Q�ca'fl for all req r inspe ons. Co late drawing or<eyerse side. <br /> Signed X Title: a Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Date <br /> Pit or Grout inspection by Date Final Inspection b <br /> i Additional Comments: <br /> WStk 466-Ml ❑ Lodi 369-3621 ElManteca 823-7104 --E] Tracy 8356385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH w <br /> i �— 13�' . <br /> ' + EH 13-241REV.1/85S �ZcD Fri --1.11 <br /> EH 14-28 <br />