Laserfiche WebLink
.p <br />APPLICATION FOR PE; IT r �(iQ.� AA Q <br />SP.N JOAQ6iN LOCAL HEALTH DISTRICT !! <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 PERMIT NO. <br />pPERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED <br />it (Complete in Triplicate) <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br />described. This application ade in compliance with San Joaquin County Ordinance No. 544 for sewage or No. 1862 for well/pump <br />and the Rules and Regulationthe San Joaquin cal Health District. <br />Job Address ;; jAV C Subdivision Name <br />Owner's Name _ Address Phone <br />Contractor's Name l ,� y License No. Phoneyj <br />TYPE OF WELL/PUMP WORK: it NEW WELL WELL REPLACEMENT F� DESTRUCTION <br />PUMP INSTALLATION SYSTEM REPAIR OTHER <br />DISTANCE TO NEAREST: SEPTIC TANK-��j'�j , _ SEWER LINES DISPOSAL FLO. <br />FOUNDATION AGRICULTURE WELL OTHER WELL <br />PROP. LINE <br />PITS/SUMPS <br />INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Industrial U•Open Bottom [� Manteca Dia. of Well Excavation ` <br />jX_Domestic/Private Gravel Pack Tracy -' Dia, of Well Casing <br />Public" <br />i Other ab Delta <br />LjIrrigation & Type of Casing <br />Approx. Eastern <br />[�Catho6c-Protection il. Depth Specifications <br />Geophysical ! Depth of Grout Seal <br />jJ Other 4 Type of Grout ._ <br />Surface Seal Installed' -by <br />Repair Work Dane Type:of Pump H. P,State Work Done <br />Well Destruction We11'Diameter xr ,r <br />_ l:_I .l � Sealing Material (top 501) ' <br />Depth 1 ! Filler Material (Below 501) r r <br />i a <br />TYPE OF'SEPTIC WORK: NEWO NSTALLATION I REPAIR/ADDITION tJ (No septic tank or seepage pit permitted if public sewer is <br />Installation will serveal Residence _ , Comme ciall Other availabhe within 200 feet.) <br />Number of living units: �I Number of bedrooms Lot size a " .- <br />Character`of soilrto,a depth of 3 feet; Water table depth <br />SEPTIC TANK Ei Type/Mf <br />9 Capacity No. Compartments <br />PKG. TREATMENT PLT. [] Type/Mfg + <br />"Capacity Method of Disposal <br />SEWAGE SYSTEM ,,F Distance to nearest: Well foundation - - - Property -Line <br />DESTRUCTION I4 _ - <br />LEACHING LINE U No. I& Length of lines <br />FILTER BED ❑ Distance to nearest; <br />Well <br />Total length/size <br />Foundation Property Line <br />SEEPAGE PITS ❑ Depth Size Number <br />SUMPS �� 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 <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />Home owner or licensed is signature certifies the following: "I certify that i6 the performance of the work for which this <br />permit is issued, I s all n t'employ any person in such manner as to become subject to workman compensation laws of California." <br />Contractor's hiring r su ontracting signature certifies the following: "I certify that in the performance of the work for which <br />this permit is.issu d, sh 11 ems oy p r/ s subject to workman's compensation laws of California." <br />The applicant mus 1 ori 1 r q 1/inspections. Complete drawingion/reverse side. <br />Signed X . Title: // ` 'y/- Date: <br />DEPARTMENT USE ONLY /&- <br />Application Accepted by Rrea (J ! St 466-67$ <br />Additional Comments:! i -T -- Lodi 369-3621 <br />.Pit or Grout Inspection by Date ���g , 4 K Manteca 823-7104 <br />Final Inspection by �� Date - `����a"1 L 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 />II <br />FEE BASE AMOUNT <br />INFO <br />AMOUNT REMITTED <br />C� 0%_ <br />RECEIVED BY <br />Ap <br />DATE <br />1&-'23-? <br />PERMIT N0. <br />f- 13(os mil <br />£H 13-24 REV. 10/82 10/82 500 <br />14--26 J <br />