Laserfiche WebLink
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 /> tion is <br /> /or install the work her <br /> Application <br /> in compliancewithwith San Joaquin Coounty Ordinance No.549 for sewage or uin Local HaI District for 8 permit <br /> No. 1862 forcwell/pump and the Rules and IRegulatidescribed. <br /> sof the San l�oaquin <br /> Local Health District. <br /> 1/f ti,rk� City Z-O p/ Lot Size J 2 PM <br /> Job Address 3 <br /> 11°ti $T'/�'` Phone � O <br /> Owner's Name /z i n L1 f LJSftfC Address <br /> (� CONST /NC. ® .,� Phone 3n/6 <br /> Contractor's Na ,_.. <br /> me �"r C License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESI RUCTION <br /> ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ElJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 3 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications 1 <br /> [1 Domestic/Private ❑ Gravel Pack ❑TracyType of Casingcy Depth of Grout Seal Type of Grout <br /> 11 Public ❑ Other ❑ Delta <br /> ❑ Irrigation ___Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 .1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONQ REPAIR/ADDITION ❑ DESTRUCTION ❑ Marl able syste200 m fn itl�d public sewer is <br /> Installation will serve: Residence— Commercial_. Other <br /> Number of living units: — Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK tT Type/Mfg FAr� CavGt4'./$apacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well &V <br /> ^I' Foundation /b 'f' Property Line <br /> ze / <br /> LEACHING LINE Q- No. 8 Length of lines 7.- Total length/si0 <br /> FILTER BED ❑ Distance to nearest: Well/ Foundation/D fi Property Line <br /> SEEPAGE PITS Depth Size <br /> 33�fc2S Number <br /> SUMPS ❑ Distance to nearest: Wal✓/Sd r <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and <br /> 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 /> man's compensation laws of California." Contractor's hiring or subcontracting signature <br /> employ any person in such manner as to become subject to work <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 applica ust call or I required inspecti s. pieta drawing on reverse side. L' ' 5—al— <br /> Signed <br /> 2/ gL/ <br /> Si ned X ��f C�� Title:� &. C �� Date: <br /> 9 <br /> FOR DEPARTMENT USE ONLY d <br /> Date `� Area <br /> Application Accepted by <br /> Inal Inspection by <br /> Date <br /> �Prt yr Grout Inspection by Data <br /> 161, <br /> Additional Comments: <br /> ❑ Stk 4666781 Lodi 369-3621 ❑ Manteca 829-7104 ❑Tracy 8366385 <br /> Applicant - Return all o ' to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BVFT:E�: PERMIYNO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO �{' <br /> . EH W4 I1EV.10/131 <br />