Laserfiche WebLink
4 <br /> APPLICATION FqR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601` E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 MAY 1 1990 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <br /> !Complete in Triplicate? ENVIIMN��IIME�+N�L��grrLrr��H.EALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woY�F�a/ddstYldl Mis application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address -` City 1-1&0'1 a Size PM <br /> Owner's Name �`�!J Address Phone <br /> Contractor Address - License NoF +Phone a2— <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION D <br /> PUMP INSTALLATION D SYSTEM REPAIR OTHER D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial D Open Bottom - 0 Manteca bia. of Well Excavation -bra. of Well Casing <br /> ,W Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications <br /> M Public Cl Other Ll Delta Depth of Grout Seal Type of Grout---.—. r <br /> I I Irrigation w--Approx. De th l 1 Eastern Su ace Seal Installed by <br /> Repair Work Done iW Type of Pump3!&:71,-1\ <br /> H.P. State Work Don <br /> Well Destruction ❑ Well Diameter -Sealing Material (top 501 _ <br /> Depth # ' +Filler Material !Below 501 Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is �1 <br /> r available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other 4 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth V' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> Distance to nearest: Well Foundation Property Line j <br /> LEACHING LINE D No. & Length of lines Total length/size � <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number . <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ j <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <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 /> 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' compe 1 <br /> tion laws of California." <br /> The applicant ca for all required i s ons. ompl to drawing on reqme side. <br /> Signed X Title: Date: <br /> EPARTMENT USE ONLY <br /> Application Accepted by Date_ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date)7 <br /> 7/ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Ll Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1.601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY DATE PERM11'No. <br /> CA5H <br /> + EH13-24IREV.riH51 �, <br /> EH 14-Z8 <br /> O �� <br />