Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT Q <br /> 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM PATE ISSUED �] <br /> (Complete in Triplicate) <br /> A <br /> Application is hereby made to the San Joaquin Local'Heal th 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 wel3/pump <br /> and the Rules nd Re�ations of the San J quin Local Health District, x <br /> I Job Address 7 Subdivision Name U <br /> Owner's Name Y \ Address Phone <br /> Contractor's Name L License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM:�REPAIR,, r❑ 1: OTHER <br /> Y DISTANCE TO NEAREST: .SEPTIC TANK # s EWER LINES' ;"d � DISPOSAL FLD. PROP. LINE V" <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Ir-^ <br /> — INTENDED USE —TYPE OF WELL PROBLEM AREA -H-^ <br /> CONSTRUCTION SPECIfiICATIONS r n <br /> J Industrial U Open Bottom [] Manteca Dia, of Well Excavation t/ <br /> Domestic/Private <br /> �.�.•L] bl _w. [] Gravei„Packe,, Tracy Oia. of Well Casin <br /> Public .-.-,--M-r-V9., _.._ _._.._ ...._ <br /> l� � Other L Deta <br /> LjIrrigation Approx. Eastern Type of Casing <br /> Depth Specifications <br /> ❑Cathodic Protection P <br /> Depth of Grout Seal <br /> Geophysical 1 � <br /> Other Type of Grout s =,�/l �1 <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done `"I 1-1y <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below501) <br /> IVI <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepagepitpermitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other t I <br /> Number of living units: Number of bedrooms Lot size (a fo <br /> Character of soil to a depth of 3 feet: V_ � _ Water table depth <br /> SEPTIC TANK Fj Type/Mfg "� , Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg l Capacity Method of Disposal <br /> SEWAGE SYSTEMe <br /> Property Line <br /> Distance to nearest: ,Well .,a s.. j Foundation Prope <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well 'k Fou dation Property Line <br /> SEEPAGE PITS Depth �� Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ { <br /> 1 I hereby certify that I have prepared'this application and that the work wiI1 be do`n'e in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin.Loca;1 "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 workman5 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> � c <br /> T e app t mu req 'red inspections. Complete F awing o revers I �}(/ <br /> 5i9 Title: Gate: <br /> TMENT US 0 _ 4 <br /> A 1ieation Acca Led by a" <br /> _pp P y �, rea �f�Stk 466-6781 <br /> Additional Comments: . ,� ? """""fes �`� Lodi 369-3621 <br /> Pit or Grout Inspection b Dat Lj'--Manteca 823-7104 <br /> Final Inspection by _ Date L7 ,Tracy 835-6385 <br /> Applicant - Return all copies6to: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box '2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE ­"IAMOUNT REMITTEDRECEIVED BY DATE I' PERMIT NO. <br />{ INFO <br /> -S a_ <br /> EH 13-24 REV'. 10/82 10/82 500 <br /> 14-26 <br />