Laserfiche WebLink
5 <br /> APPLICATION FOR PERMIT <br /> SAN JOAO,UIN iOCAt HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 JUL 2 2 1985 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ;ENV(' Q:�I 1TAL' HEALTH <br /> (Complete in Triplicate) ;., ^''F FN <br /> T Mlication is <br /> App, and the Ryles and Regulations of the San Joaquin <br /> lication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work eree r <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No; 1862 for well pump <br /> 1 Health District <br /> Laca •� • :r � - PM , <br /> ?^fit City <br /> Lot Size <br /> Job Address <br /> Phone <br /> 4 •Address ,. <br /> Owner's Name _ <br /> a © ense No. �� Phone <br /> < Address I <br /> Contractor WELL REPLACEMENT DESTRUCTION Q <br /> TYPE OF WELL/PUMP: NEW WEL OTHER ❑ <br /> SYSTEM REPAIR ❑ <br /> i PUMP INSTALLATION d DISPOSAL FLD.IO�;'! PROP. LINE <br /> SEWER LINES 'PITS/SUMPS <br /> _ <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> 'INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom C1 Manteca `Dia. of Well Excavation <br /> ❑ Industrial Specifications W <br /> i�Gravel Pack Tracy Type of Casing ; <br /> Domestic/Private ❑ pelta Depth of Grout Seal Type of ut <br /> ❑ Public *, - ❑ Other' <br /> l _�pprox. Depth ❑ Eastern Surface Seal Installed <br /> i n Irrigation State Work Done <br /> H P <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 50'1 <br /> Well Destruction Q Well Diameter <br /> -Q-Q-P "`J'R� Depth Filler Material (Below 50'1 <br /> available within 240 feet-) <br /> TYPE OF SEPTIC ORK: NEW INSTALLATION ❑ EPAIRIADDITION ❑ DESTRUCTION F-1 (4Vo septic system permitted if public sewer is <br /> R <br /> Commercial— Other <br /> installation will serve: Residence <br /> Number of living units: Number of bedrooms Water table depth <br /> e Character of soil to a depth of 3 feet: Capacity— No. Compartments A <br /> i SEPTIC TANK ❑ Type/Mfg `Method of Disposal <br /> PKG. TREATMENT PLT. <br /> IDDistance <br /> gyp-Property Line r <br /> 1 Distance to nearest: Well \ <br /> f <br /> Total length/size <br /> LEACHING LINE 6 ❑ No. & Length of lines Property Line <br /> Foundation _ <br /> FILTER HED .. ❑ Distance to nearest:' Well 4 <br /> I <br /> Number <br /> Size <br /> SEEPAGE PITS y ElDepth Foundation Property Line <br /> SUMPS ; LlDistance to nearest: Well <br /> DISPOSAL PONDS 1 F1 ' <br /> �-^-§ application and that the work,will be done in accordance with San Joaquin county ordinances, state Laws, and � <br /> l hereby certify that I have prepared this app <br /> srules and regulations of the San Joaquin Local Health District.gthat in the ; <br /> Home owner or licensed agent's signature as tobecome subject Ito workman'scompensationpensatian lawsoof California. Contract r'slhiri b c sub-contracting n' c signature i <br /> employ any person in such mann Persons subject to workman's compensa <br /> t certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ <br /> f tion laws of California." <br /> r The applant ust call for all req inspections. Complete drawing on rev IsiS t rDate: <br /> Title: <br /> SignedFOR DEPARTMENONLY - <br /> - Date Area <br /> w Application Accepted by - / '. Date <br /> pit <br /> Date Fal Inspection by <br /> it or Grout inspection by <br /> k Additional Comments: <br /> El <br /> Lodi 369-3G21 Manteca 823-7184 ❑ Tracy 835-63852009,.Stk., CA 95201 <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O- Box <br /> ❑ Stk 466-6781 <br /> RECEIVED BY DATE PERMIT N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH pS�g3S <br /> INFO ; �Z ZS 4 <br /> ' + EH 13-24(REV.1/s 5) <br /> EH 14-28 <br />