Laserfiche WebLink
7/ <br /> APPLICATION FOR PERN,;; <br /> s <br /> SAN 3CAQU,N LOCAL H_ALTH DISTRICT <br /> 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. [ ~ `� �� <br /> Telephone {209) 466-5781 r <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED` <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local'Health District for ap4 <br /> l the <br /> described, This application is made in compliance with San Joaquin County Ordinance 549tfordsewagearor' soalNo.. i862rforewell/pump . <br /> and the Rules and Regula ions of the S�j' Joaquin Local Health District, <br /> Job Address C,J . Subdivi ion ame X%f <br /> Owner's Name <br /> Address CaC ne 3/— <br /> Contractor's Na e i <br /> License No. PhonebUr" <br /> si <br /> TYPE OF WELL/PUMP WORKS NEW WELL WELL REPLACEMENT DESTRUCTION <br /> i <br /> "PUMP-INSTALLATIOM- SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k INTENDED USE TYPE OF WELL PROBLEM AREA y CONSTRUCTION SPECIFICATIONS <br /> J Industrial ~ <br /> U Open Bottom []Manteca �"pia'of-Well EiCc�vatio�s <br />' h( Domestic/Private ❑ Gravel PackTrac <br /> .�] Publics-, y .� r -� -Dia. of Well Casing <br /> [].Other �] Delta <br /> Li Irrigation Type'of Casing <br /> Approx. [� Eastern <br /> Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done [J Type of Pump H.P. State Work Done <br /> Well D <br /> est <br /> rc <br /> u tion <br /> U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material;(Below 50') <br /> REPAIR/ADDITION U (No septic tank or'seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L <br /> Installation will serve: Residence r Commercial Other-, available within 200 feet.) a <br /> Number of living units: Number of bedrooms ot�s-Ze4 / p <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg <br /> z a <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. T e I <br /> ❑ Mf <br /> Yp / 9 Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION � <br /> LEACHING LINE No. & Length of lines - �- .�.�. .. ­- . Total length/size L4 m <br /> FILTER BED Q Distance to nearest: Well .'alb Foundation. <br /> ' (0 Property Line <br /> SEEPAGE PITS' LB' Depth o!$J Size Number 1 <br /> SUMPS Distance to nearest: Well 5�,Vf_ Foundation 4(0 Property Line <br /> 54 <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 <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 any person in such manner as to become subject to workman compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is-issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant ust call for' 11 re uired inspections. Complete drawing on reverse side. <br /> Signed.X ,( <br /> Title: _ Date: �'��'"d <br /> R ARTM USE ONLY ` - <br /> Application Accepted-by Area �/ Stk 466-6781 <br /> Additional Comments: Lodi 369-3623 <br /> Pit or Grout Inspection by Date <br /> Manteca 823-7105 <br /> Final Inspection by Date �- � Tracy 835-6385 <br /> Applicant - Return all copies to: Environmentalealth Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 I <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br /> I <br />