Laserfiche WebLink
4 <br /> APPLICATION FOR PERMIT �� <br /> f SAN JOAQUIN LOCAL HEALTH DISTR <br /> 1601 E. HAZEL T ON AVE., STOCKTO , CA <br /> Telephone {208} 466-6781 <br /> 11 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 2 f lc79 <br /> (Complete in Triplicate) [��{ [ r� 7 ! <br /> R0A4i�FAhdr hdl'Tib-�IdpP4-6-n is s <br /> Application is hereby made to the San Joaquin Local Health District for agpermit to construct and/or instal FpCe I� <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the e e ti 5 San Joaquin <br /> Local Health District- <br /> City Lot Size PM <br /> Job Address <br /> �j 1s- ,.e2�A � . Phone <br /> Owner's Name�1--�J _ Address <br /> O ) / <br /> Contractor'--),— <br /> Address License No./tn_ �3?3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJDESTRUCTION ❑ i <br /> PUMP INSTALLATION 6-4/ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL-,".-' <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Industrial [I Open Bottom ❑ Manteca <br /> Type of Casing Specifications <br /> �mestic/Private ❑ Gravel Pack F1 Tracy <br /> 9 <br /> I� Other Cl Delta Depth of Grout Seal Type of Grout <br /> FI Public _ <br /> I I Irrigation _.-Approx. Depth t I Eastern Surface Seal Installed by <br /> J State Work Done <br /> , - Repair Work Done ❑ Type of Pump H.P. �. v\ <br /> ._,INes Destruction 0 Well Diameter Sealing Material Itop 501 <br /> Depth` Filler-Material-fBelow'501-'-"' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I-] (No septic system permitted if public sewer is <br /> available'within"200 feet.) <br /> Installation will serve: Residence_ Commercial, Other <br /> Number of living units: Number of bedrooms <br /> •. Water table depth <br /> CharactdrTf-s0Wt0-a-dePth'0f 31cet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ~f <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> NO <br /> 'Distance to nearest;- i Well Foundation Property Line <br /> s Total length/size <br /> LEACHING LINE ❑ No. & Length of lines. S <br /> � . <br /> FILTER BED ❑ Distance to nearest—: Well Foundation I Property Line <br /> SEEPAGE PITS l I Depth Size — Number <br /> _ SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> '^=DISPOSAL PONDS ❑ <br /> 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 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 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:'9,certify i'hbt in <br /> the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa= <br /> tion laws of California." ' <br /> ' The applican st c for all r 'ed inspections. Complete drawing on reverse side. r <br /> Signed X t itle: <br /> Date: <br /> 1- <br /> FOR DEPARTMENT USE ONLY <br /> r 013,/ <br /> Date Area -u <br /> `Application Accepted by � <br /> Date <br /> Pit or Grout Inspection by s. Date Final,Inspection by f <br /> Additionat Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> - -74+.EH 13-24 1REV-t i N 51 j � <br /> EH 14.28 <br />