Laserfiche WebLink
f - 5 <br /> APPLICATION FOR PERMT <br /> SAN JOAQUIN' LOCAL HELTH. DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT W S S- AC-�' % <br /> Telephone (_09) 466-6781 <br /> 81 , <br /> f ; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 9 <br /> (Complete in Triplicate) i <br /> i <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 the San Joaquin Local Health 'District. <br /> Job Address 16 yQ w657` � ,�`i Subdivision Name <br /> Owner's Name _ %� �� f� Address A/0Q_ r-p1� / � _ _ _ TT Phone <br /> Contractor's Name License No. P h a n e <br /> i <br /> TYPE OF WELL/PUMP WORK: NEL! WELL WELL REPLACEMENT DESTRUCTION �) i <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> -- -•-DISTANCE TO-NEAREST.--SEPTIC TANK--»— - - -•SEWER�L-INES--:­­-DISPOSAL-FLO. _ PROP.-••LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL, - PITS/SUMPS T i <br /> INTENDED USE TY?E OF WELL PROBLEM AREA - - CONSTRUCTION SPECIFICATIONS <br /> . -Industrial_ .-w- w— . U-Open;Bottom—F-1 vanteed Dia..of-Wel 1..Excavation. t <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public <br /> Other Delta - -. Type of Casing <br /> TI-IrrigaVon Approx. Eastern <br /> Specifications <br /> Cathodic Protection Depth r <br /> r � `� � Depth of Grout_Seal <br /> Geophysical Type of Grout O <br /> Other y ' Lh <br /> ;Surface Seal Installed by <br /> ,x <br /> -Repair Work Done El Type of Pump n H.P. State Work.Done <br /> Wel I Dest-ruction U;ti Well Diameter- Seal i ng'Mteri'al (tap 501-)- <br /> , <br /> Depth *" Filler Material (Below 50'-) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION reREPAIR/ADDITION'-� (Na septic"tank or seepage pit permitted if public sewer is <br /> +�►.� available within 200 feet.) i <br /> Installation will serve: Residence : Commercial _ Other '� s <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: A' r"�� Water table depth - a <br /> SEPTIC TANK Type/Mfg. Capacity _ No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest:- Well,*o F1-Foundation WT- Property Line <br /> DESTRUCTION 11 l <br /> LEACHING LINE U No. & Length of lines 1"~ !D X ��- Total length/size <br /> FILTER BED Distance to nearest. Well F17oundation � Property Line <br /> SEEPAGE PITS D Depth } Size Number <br /> T5'SUMPS L1 Distance;to nearest: Well Foundation Property Line <br /> DISPOSAL,.PONDS <br /> I hereby certify that I"have prep6red 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-age`nt's signature certifies the following: "I certifysthat in the performance of the work for which this <br /> permit is issued, I shall not employ any person in st9ch-manner'as' to-become•subject to workmant 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 must c 1 for ll required inspections. Complete drawing on reverse side. <br /> Signed X ,Title: Date: <br /> FOR RTMENT USE ONLY <br /> ,Application Accepted by ' � �/LGl/h- Area 13 ___ Stk 466-5781 <br /> Additional Comments, ❑ Lodi,. - 369-3621 <br /> Pit or Grout Ihspection Dateanteca 823-7104 I <br /> Final Inspection by Date ��� ❑ Tracy 835-5385 i <br /> Applicant - Return all copies, to: Environmental Health Permit/Services 1 O1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> a <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />