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"Y€AR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applll the work <br /> is <br /> made in conmplihereby ance with Saade n Joaquithe n County Ordinance n Joaquin lNth District for a o.549 for sewage or permit <br /> No. 1862 for welUpump and the Rules and'Regulations of trhe Sanapplication <br /> Joaquin <br /> Local Health District. <br /> 20 zl� S, Y <br /> Job Address City C <br /> Owner's Name • 1 Address Imo' PM <br /> Phone <br /> Contractor <br /> Address 350 C License No. aL Phone a �s <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ )V , <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Il Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> —.— <br /> I I Irrigation --Approx. Depth i I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I RUCTION I i INa ailabetiwithin system <br /> permfe fitted if public sewer is <br /> Installation will serve: Residence"'Gommercial Other <br /> Number of living units: —]— Number of bedro ms <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Y ftE� iii? 11 <br /> apacity��anNo. Compartments <br /> PKG. TREATMENT PLT. 0 Method a1 Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE go. & Length of lines 1 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS +;�}�istance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 0 <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, 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 /> 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 /> certifiesAbp 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 o lifornia." <br /> The applicant t call o all re uired i pec'ons. C�amplete drawing on�erse�siid .Signed Title: D te: P FOR EPARTf1MENT USE ONLY � / <br /> Application Accepted by r <br /> /v Date ��� ��� Area <br /> �spection by Date Final Inspection by Date n <br /> Additional comments: <br /> 144mnigI L,( /i�l <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT RUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> 7J♦ EH 13-24(REV,i/K51 •-r 9 Z �/ F,7 35T- <br /> EH 14-25 i` <br />