Laserfiche WebLink
77 <br /> APPLICATION FOR PERM!! I1 <br /> SAN JOAQUIN LOCAL HEALTH ]]STRICT <br /> a <br /> 1601 E. HAZELION AVE., STCCKTON, CA PERMIT NO. ��C- <br /> TL <br /> I <br /> lephone (209) 466-6781 <br /> PERMIT ERPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED i i <br /> (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 is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations}, g�o/f the S n�aq �ca s h District. <br /> Jab Address LJ 1� Su <br /> ision Name <br /> Owner's Name e� � s �—��o` �y r ��ZPhone <br /> Contractor's NaVY l. , d� License Na, Phone <br /> TYPE OF WELL/PUMP WORK: NEW! WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U <br /> PUMP INSTALLATION L] SYSTEM REPAIR ❑ OTHER..U _ + <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL_DI PROP. LINE` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL'- <br /> ELL PITS/SUMPS 1 <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS1-1 1 <br /> Industrial ❑ Open Bottom Manteca k , •# Dia. of Well Excavation <br /> F-1Domestic/PrivateGravel Pack_ Tracy _ r . Dia,. of Well Casing <br /> ❑Other Delta <br /> V Irrigation Approx. Eastern Type of Casing i <br /> Cathodic Protection Depth Specifications <br /> Depth of Grout Seal r� <br /> Geophysical r-��. � O <br /> ❑Other Type of Grout <br /> Surface Seal Installed by ! <br /> Repair Work Done FJ Type of-Pump -- . -H-. State-Work Done ti <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501) " <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ' <br /> available within 200 feet.) <br /> Installation will serve: Residence _L,, A Commercial Other <br /> Number of living units: ,-__L-- Number of,bedrooms - — Lot size _ j_ 2-. Y <br /> Character of soil to a depth of 3 feet:- Water table depth ' <br /> SEPTIC TANK CtJ Type/MfgCapacity _i o (..Nv. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg { Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well ' Foundation <br /> DESTRUCTION Property Line f <br /> ❑ w <br /> LEACHING LINE No. &-Length of lines - C/($, Total Iength/size - <br /> FILTER BED Distance to nearest: Well Foundation Property Line 1 - <br /> SEEPAGE PITS Depth Size Number _ <br /> SUMPS Distance to nearest: Well Foundation a Property Line W <br /> DISPOSAL PONDS �� u <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 agent's signature certifies the following: ''I certify that in the performance of the work for which this <br /> permit is issued, I'shall not employ an erson in such manner as to become subject to workmank compensation laws of California." <br /> Contractor's hiring or sub-contracting •gnature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issue I steal e oy p s ns subject to workman's compensation laws of California. <br /> i. " <br /> The ap I s .�pections. Complete drawing on reverse side. <br /> Signed Title: Q _Date: <br /> 0 DEPARTMENT US ONLY <br /> Application Accept d by Area / 7 Stk 466-6761 <br /> Additional Comments: 0 Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by ...:*/ Date _Tracy 835-6185- ^A11tCgg 1NS <br /> Applicant - Return all copies to: Envir ntal Health Permit/Services 1601 E. Hazelton AVE., P.O. Box 2009, Stk., CA 95201 ll <br /> FEE BASE AMOUNT, DUE AMOUNT REMITTED RECEIVED BY DATE 'PERMIT-NO. <br /> INFO - <br /> S <br />� n f "4. r # <br /> �., EH 13-24- REV. 10/82 lf.+t�L 10/82 500 ! <br /> 14-26l <br />