Laserfiche WebLink
I A <br /> APPLJCATION FOR PERMIT . <br /> SAN,JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. `J <br /> Telephone (209) 466-6781 z <br /> DATE ISSUED Q � <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 <br /> described, This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of thee SanJoaquin Lo�ppl. Heal District. <br /> Job Address, "I' (� �/ e g impflAg.bdi0 ion Name <br /> Owner's Name Address Phone <br /> Contractor's Name 4 F7 <br /> License No. 1_y3.3 ti _ Phone / <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE °' TYPE-6P-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial: ❑ Open-Bottom r"^ Manteca_ . Lz :Dia of,Well.Excavation yL J <br /> ❑ Domestic/Private❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Pd6lic, Delta z <br /> ❑ ❑ Other ❑ Type of Casing <br /> Irrigation i Approx. ❑ Eastern + <br /> t Specifications <br /> Cathodic Protection Depth <br /> ! <br /> ❑ p - Qepth of Grout Seal <br /> ❑Geophysical 4',, Type.of I <br /> Grout <br /> 4 <br /> ❑Other Surface Seal Installed by <br /> Repair Work,Done ❑ Type of Pump H.P. State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (top 5O') _ s <br /> ' <br /> Depth._,-. ._,_ Filler Material {Below 501} <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION E:I•-REPAIR/•ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200:feet.) <br /> Installation will serve: " Residence Commercial — Other <br /> Number of-;l"iuing-units Number oflbedroams4_- L7 _size_e__ " <br /> Character1`oT'soil too depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg _eo� Capacity No. Compartments <br /> PKG. TREATMENT-.,PLT. ❑ Type/Mfg -: s Capacity " Method of Disposal' <br /> SEWAGE SYSTEMi Distance to :nearest: Well Foundation Property Line . <br /> DESTRUCTI- p <br /> LEACHING LINO No. & Length of lines Total length/size V' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line , <br /> H <br /> SEEPAGE PITS Depth Size Number ' <br /> SUMPS ��� Distance to nearest;"Wel 1 f�f�' 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 <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 r. <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> !�The applica must call for required ins actions, Complete dr wing on reverse side. <br /> Signed x Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by rea`!J ❑ Stk 466-678 <br /> Additional Comments: I Lodi 369-3621 <br /> Pit or Grout Inspectio by Date ii <br /> JJ❑ Manteca 823-7104 <br /> Final Inspection by Date 1� �{ Tracy 835-6385 <br /> Applicant - Return all copies of Environ ental Health Permit/Services 1601 F. H zelton Ave., P.O. Sox 2004, Stk., CA 95201 <br /> �.g <br /> FEE BASE AMOUNT DUE: AMOUNT.REMITTED RECEIVED BY ­OATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 506 <br /> 14-26 <br />