Laserfiche WebLink
APPLICATION FOR PERMIT, <br /> SAN JOAQUIN -L'OCAL HEALTH DISTRICT <br /> 4 ?; <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1`-YEAR'FROM DATE -ISSUED'," <br /> (COmPI6 i6 . ..Triplicate)' <br /> in . <br /> Application is hereby made to the San Joaquin Local Health District for a permit to'construct an <br /> d/or install the work herein described. This application-is i <br /> made in compliance with San-Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Re"gulations of the tan JoaqLiin <br /> Local Healih District. n. -42; 1e,- 4 k, <br /> T <br /> Job Address K, Lot S Ze' PMKAS <br /> Owner's NamPhone <br /> Addrd:g:s <br /> bax <br /> ContractoAeA6AI��z Add res License No. —Pho <br /> TYPE OF WELL/PUMP: NEW WELL C] WELL REPLACEMENT El DESTRUCTION 0 <br /> PUMP INSTALLATION El ...SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES - DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION'�—��—AGRICULTURE WELL—__T_­-OTHER_WELL.'_-_:!!_ -PITsTnU_Q[P-S_—; <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS 4 <br /> Ll Industrial C1 Open Bottom 13 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Dome6tic/Private C1 Gravel Pack El Tracy T Type of Casing Specifications <br /> Ll Public D.Other .:T.- . D.Delta.;. .. -.--.,;Depth-of4Grout.Seal,-- Type of Grout <br /> EI Irrigation -L-Approx. Depth O'Eastern Surface Seal Installed by <br /> Repair Work Done Ll Type of Pump H.P. State W.rk',D.n'p <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth Filier Material iBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION _REPAIWADDITION-Cl< DESTRUCTION M (No septic system permitted if public sewer is <br /> i T . f I -_" , k-_ available Within 200 feet,) <br /> Installation will serve: Residence Commercial— Other <br /> 4­ <br /> Numbdr of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet- Water table depth G <br /> SEPTIC TANK ><Type'/MfQ Capacity--h aN6- Compartments <br /> PKG. TREATMENT PLT.--El -i <br /> Method of &P-0"Sal <br /> Distance to nearest: Well 0 Foundation Property Line <br /> <,-70 <br /> LEACHING LINE- ><No;-& Length of lines • Total length/size- <br /> 6 <br /> FILTER BED C1 Distance t6 nearest: Well Foundation Property Line.—,,._, <br /> ..SEEPAGE PITS—, -NUmber-1-2 <br /> SUMPS D Distance to nearest: Well ­�,'Foundatjo`nl", • :P .-Property Line <br /> DISPOSAL PONDS 11 <br /> I hereby certify that-I have prepared_this application and that the work Will'be dohs in accordance with San Joaquin county ordinances, state]a w's, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed such <br /> certifies the following: "I cerW 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's compensa- <br /> tion laws of Californi <br /> The applicant f al requ' omplete drawing on reverse sidg. <br /> Signed Title: Date. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ' - . � -,.% �_ D <br /> XA ate Area <br /> IN A"_l Date <br /> Pit or Grout In i Bpection by Date Final Inspection by <br /> f -T <br /> Additional Comments:mments, <br /> I-] Stlk 466-6781 0 Lodi 369-3621 Manteca 823-7104 0❑Tracy 835-6385 <br /> Applicant- Return all copies to. Environmenta Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2", Stk., CA 95920I <br /> FEE AMOUNT DUE CK#_-) By <br /> INFO AMOUNT REMITTED RECEIVED -DATE PERMIT`NO. <br /> + EH 13-24 1 REV.1 85 <br /> EH W26 <br /> �ZN CS R- <br />