Laserfiche WebLink
f APPLICATION FOR PERMIT <br /> �� � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work <br /> Application is hereby made to the Sen Joaqui <br /> n <br /> Ld'inanca lHealth District for a No.549 for sewage or permit <br /> No. 1862 forcwell/pump and the Rules and rRegulations of ti This hcation is <br /> e San l Joaquin <br /> made in compliance with San'Joaquin county O <br /> Local Health District. r ,.. <br /> V <br /> f Lot Size PM <br /> City --�—� <br /> Job Address P <br /> Phone <br /> Address <br /> 9 <br /> Owner's Name <br /> �y _ <br /> ' t p� ��� �� 7 License Na Phone <br /> Contractorallh <br /> 71 v .. Address_�� <br /> WELL REPLACEMENT IJ DESTRUCTION <br /> TYPE OF WELL UMP: NE ELL 13OTHER El <br /> -» PUMP INSTALLATION D <br /> SYSTEM REPAIR C1 <br /> SEWER LINES l-- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK. OTHER WELL PITSlSUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> .INTENDED USE --,—'TYPE'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> Dia. of Well Excavation <br /> " <br /> El Industrial D Open Bottom C1 Manteca❑ <br /> Gravel Pack T <br /> Specifications <br /> O Domestic/Private <br /> Type oGasing <br /> 4 Cl racy yp f <br /> f�l Other Cl Delta Depth of Grout Seal Type of Grout <br /> h <br /> f-1 Public Surface Seal Installed by <br /> OkIrrigation ,.Apprax. Depth i ! Eastern P <br /> H. . State Work Done <br /> = <br /> Repair Work Done U Type of Pump _ e4od-1 <br /> Well Diameter ^_�. Sealing Material I1 <br /> Well Destruction n�� Filler Material IBelowi* <br /> Depth rir <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t:l REPAIRIADDITIDN l I DESTRUGTION i I available within 200 feet(No septic system .) if public sewer is <br /> will serve: Residence Commercial_, Other <br /> installation ' <br /> Number of living units: Number of bedrooms Water table depth Ic <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments .� <br /> F SEPTIC TANK D Type/Mfg. Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> k Distance to nearest: Well Foundation_. <br /> i Total length/size <br /> LEACHING LINE D No. & Length of lines Property Line <br /> FILTER SED <br /> [� Distance to nearest: Well Foundation <br /> ,I <br /> Number <br /> SEEPAGE P1TS l l Depth <br /> Size _ <br /> t Foundation Property Line <br /> f SUMPS C1 Distance to nearest: <br /> Well <br /> I DISPOSAL PONDS ❑ <br /> . a .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 Hearth Dllowi .g 11 this permit is issued, <br /> Horne owner or son in h manner tore certifies thebecome subject workman'srtcompensation lify that in the aws Of Califorrnia." Contractor's�hiring of sub-contracting lsignat shall ore <br /> employ any pe arsons sub'ect to workman's compensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." <br /> The applicant t eq fired ins s-6omplete drawing on reverse side. <br /> Date: <br /> Title: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY f �`1 f <br /> I� L�^""-'� Date a Area d II <br /> Application Accepted by L <br /> LL 'x <br /> Final Inspection by Date <br /> Pit or Grout Inspection by Date <br /> Additional Comments: <br /> Y <br /> l ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-71D4 ❑ Tracy 536 6385 — <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> ffCK RECEIVED 6Y DATE PERMIT'NO. <br /> nWT%! <br /> ED <br /> EH 1324(REV.1/a5) <br /> EH 14-25 <br />