Laserfiche WebLink
'� I! 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 />�I (Cornplete in Triplicate) <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct andf or install the work herein described. This applicatirxl is <br />made in compliance with San Joaquin County Ordinance No. 549 for sewage of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br />Local Health oistrict. <br />Job Address ii r� <br />City Lot Size PM <br />Ownei s Name <br />' i <br />Address a40516b <br />u aE <br />(f Phone <br />Contract <br />Addresst D . %Q}Gse Nc i o Phone <br />� <br />TYPE OF WELL/PUMP: <br />11 NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br />FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Industrial <br />❑ Open Bottom ❑Manteca Dia, of Welt Excavation s Dia. of Well Casing <br />❑ Domestic/ Private <br />❑ Gravel Pack ❑ Tracy YP 9 Type of Casin t Specifcations <br />( Public <br />M Other 17 Delta Depth of Grout Seal Type of Grout <br />Irrigation <br />,..Approx. Depth i 1 Eastern Surface Seal Installed by <br />Repair Work Done ❑ <br />Type of Pump H.P.- <br />State Work Done =_ <br />Well Destruction O <br />Well Diameter Sealing Material (top 50'] <br />Depth I� Filler Material IBelow <br />TYPE OF SEPTIC WORK: <br />NEW11 .INSTALLATION 11 REPAJR/ADDITION' ESTRUCTION i I (No septic system permitted if public sewer -is <br />Installation will serve: <br />Residence Commercial Other available within 200 feet.) <br />^, <br />Number of living units: Number of bedrooms <br />Character of soil to a <br />�► - <br />depth of 3 feet: ��b f! �li�� <br />SEPTIC TANK <br />Water table depth <br />❑ Type/Mfg Capacity_ <br />PKG. TREATMENT PLT. <br />aNo. Compartments <br />❑ <br />Method of Disposal <br />i + r t <br />Distance to nearest: Well WO Foundation 4340, Property Line <br />LEACHING LINE <br />No:'& Length of lines <br />ILTER BED <br />Total length/size <br />❑ Distance to nearest: Wetter% Foundation Property Line <br />iEEPAGE PITS <br />I I Depth Size Number <br />SUMPS <br />0 Dis;l nce to nearest: Well F6u4'dation3 <br />Property Line <br />)iSPOSAL PONDS <br />❑ �� ., •. <br />_ .� <br />hereby certify that I haves r%ranardr! ♦hic ,.0 <br />---- - - •• ­ •- —, - I — - .r. accuruance wan aan Joaquin county ordinances, state laws, and <br />rules and regulations of the San Joaquin Local Health Di`�trict. <br />Horn` a <br />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 y person in h matlner'as to become bieci to workman i*&ii: perisation laws Df California:"'Contactor's-hiring orsub-contracting signature <br />certifies the following: I certify shalt in the pe rf hce of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- <br />tion laws of CaGfo 1 i� I <br />The appli nt t U for all requir ns ction Co ete <br />ng on reverse side. <br />Signed X �� $ <br />Title: Date:ji <br />! <br />FOR DEPARTMENTTUSE ONLY k <br />Application Accepted by E .a <br />I Date Area t' O <br />Pit or Grout inspection by Date Final In ' <br />speccon by <br />Additional Comments,, — <br />❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7184 D Tr6 Y 835-X38 ---- <br />Applicant - Return all copies to: Environmental Health Permit/Services 1681 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201` <br />fI A <br />a. EH 13-24 (REV. I/ a <br />EH 1426 <br />Date // /? rJ <br />V <br />d <br />