Laserfiche WebLink
� I <br /> APPLICATION FOR`PERMIT' <br /> I <br /> SAN JOAQUIN'LOCAL .HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA, PERMIT NO. r <br /> Telephone (209) 466-6781 <br /> . DATE ISSUED off t Zr <br /> -- PERMIT EXPIRES I'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 a i Re ulations of. t1fSan :Joaquin totalealth District. <br /> Job Address I A Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ -WELL REPLAGEMENT,,�E r.1#DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM}REPAIR ❑ OTHER ❑ r <br /> DISTANCE.•TO-.NEAREST:-:SEPTI C -TANK,__-i - - +wEWE{1-L-INfS - DISPOSAL FLD: PROPTLINE Tom' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # <br /> Industrial ❑ Open Bottom []Manteca Dia. of Well Excavation <br /> �U.DomesticLPrivaxe_Q-Gravel-Pack [Q Tracy Dia: of-Wel-l-Casing <br /> 0 Public ❑ Other 0 Delta Type of Casing <br /> L_11rrigation Depth ❑ Eastern <br /> Depth Specifications <br /> Catodicroecon 1 <br /> Cathodic Ptti <br /> ❑ Depth of Grout Seal , <br /> Geophysical Type of Grout <br /> [❑Other r Surface Seal Installed by <br /> Repair Work Done ElType of Pump tate Work Done 3 ' <br /> Well Destruction ❑ Well Diameter ) Sealing Material (top 501) _ <br /> Depth p` fFiller:Maierial„(Below 50') ! .4 {- <br /> t <br /> TYPE OF SEPTIC WORK: NEW. INSTALLATION L REPAIR/ADDITION (No septic tank or seepagejpit,1permit"ted -if public sewer is <br /> i ,,,//� available within 200 feet.) <br /> Installation will serve: sidence _i Commerc'ial, "X-Other _ <br /> Number of living units: Number lof bedrooms Lot size LJ tet` ;[ rC:S 1 <br /> Character of soil to a depth of 3 feet: "l Water table depth I <br /> SEPTIC TANK ❑j Type/Mfg Capacity No. Compartments l i <br /> PKG. TREATMENT PLT. ❑ Type/Mfg s U Capacity Method of Disposal l s <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property,Line <br /> DESTRUCTION <br /> j_.EACHING LINE E] No. & Length of lines f Total length/size l <br /> 'FILTER BED Distance to nearest: Well !Foundation Property1 iLine <br /> ��yyyyGGGGGUJJJJJ <br /> SEEPAGE PITS ❑ Depth ; Size Number i r� <br /> SUMPS LJ Distance`to nearest:We11 -•""l Foundation Property`Line <br /> DISPOSAL PONDS ) <br /> I" ' tQ <br /> hereby certify`1hat I have this application and that the work will be done in accordance oaqu co <br /> nce with San unty <br /> *U <br /> ordindnces,'.state laws, and rules)and regulations of the San Joaquin Lqcal Health District. <br /> Home owner or i_icensed'agent's signature certifies the fallowing: "Ilcertify that in,therperformance of the work for which this <br /> permit is ;issued, I shall not employ any person in such manner as to become subject'to warkmans compensation laws,of California." <br /> C tor''s hiring=or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this•pe is i s d, I shall ploy p rsons subject to workman's compensationjlaws of-Californnia _ •_3 <br /> Th clic n us 1 Q it . sp tions. Complete dr inion <br /> Sign Title: { SLADate: <br /> a FOR DEPARTMENT USE ONLY Isw <br /> Application,Accepted by i r �. f' I Area �� ( Stk 466-6781 <br /> Additional 'Comments; ❑ Lodi 369-3621 <br /> Pit or Grout Inspection Date 0 Manteca B23-7104 <br /> final Inspection by Date i ❑ 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 BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> ,.o Z1 � 3. -� o <br /> EH 13-24 REV. 10/82 =4 10/82 500 <br /> 14-26 <br />