Laserfiche WebLink
r <br /> *e <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �7,3= l <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <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 Re ul ions of, he Sa Joaquin Local Health District. <br /> Job Address j Subdivision Name <br /> Owner's Name Address �, �� Phone <br /> Contractor's Name L �L��}� License No. � Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTIQN E] y <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IJ Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> L}Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing <br /> Public F-1 Other Delta Type of Casing <br /> V Irrigation Approx. [] Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal M <br /> ❑Geophysical Type of Grout <br /> Other Surface Seal Installed by l <br /> Repair Work Done D Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') J <br /> Depth Filler Material (Below 50') —� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,AeITION (No septic tank or seepage pit permitted if public sewer is <br /> tl� available within 200 feet.) <br /> Installation will serve: Residence K Commercial _ Other <br /> Number of living units: A— Number of bedrooms Lot sizey c-71 <br /> Character of soil to a depth of 3 feet: V Water table depth <br /> SEPTIC TANK EJ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation _ Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Distance to nearest: Well 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 <br /> this permit is issued I shall ploy persons subject to workman's compensation laws of California." <br /> 'he app i st ca 1 f 11 r q 1 e inspections. Complete d win on reverse �d�e. � �, <br /> Si Title: 9 A /'�T Dat <br /> -FOR DEPARTMENT USE ONLY s <br /> Application Accepted by Area j' Stk 466-6781 <br /> Additional Comments: [] Lodi 369-3621 <br /> Pit or Grout Inspection by Date ,?3- Manteca 823-7104 <br /> Final Inspection by m Date r �3 ❑ 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 /> EH 13-24 REV. 10/82 O 10/82 500 <br /> 14-26 ' <br />