Laserfiche WebLink
10 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <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 described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, <br /> Job Address <br /> 24694 Dustin Rd* ,ACaMP09 City AC UC — Lot Sae 5aC* PM <br /> Owner's Name <br /> Harry Dale Const —* Address 10133 Twin Cities Galt Ca Phone 745-282 <br /> _ - ---- <br /> Contractor Woods, Well Drilligddress 11944 Simmerhorn Rdticense No. 2$2866 Phone 745-2407 <br /> TYPE OF WELL/PUMP: NEW WELOC WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONS] SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 50 SEWER LINES __1301 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 50 AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tt <br /> ❑ Industrial " J Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> R Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications 12 ; <br /> 1"1 Public ❑ Other R Delta Depth of Grout Seal 50 Type of Grout n &Cel t <br /> Depth l I Eastern - <br /> I I Irrigation ---Approx. Surface Seal Installed by Woods P <br /> Repair Work Done L1 Type of Pump SUB H.P. 11 State Work Done i <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50 <br /> Depth Filler Material lBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION I I DESTRUCTION I i iNo 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 /> Character of soil to a depth of 3'feet: Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line } F <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line v <br /> Number <br /> SEEPAGE PITS l 1 Depth Size <br /> SUMPS ❑ Distance to nearest: Wel 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: "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 California." <br /> The applicant must fo all req ui ed inspe s. Complete drawing on reverse side. <br /> Signed X / Title: Date: <br /> 1I/14 88 <br /> F Of <br /> USE ONLY <br /> Application Accepted by —, <br /> Date 1 Area <br /> Pit or Grout Inspection by ` C y Dated=/ ` yrinal lnspectiorl by <br /> Date 7!-Z z <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-362Y ❑ Manteca a23-7104 ❑ Tracy, 835- 5 <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> OAZ <br /> + EH 13241NEV.1/A51 + � <br /> V EH 14-26 P <br />