Laserfiche WebLink
i <br /> F APPLICATION FOR PERMIT <br /> 4 SAN JOAQUIt! LOCAL -EALTH 15TRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> !s Telephone (209) 466-6761 q <br /> DATE ISSUED [ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r� <br /> k (Complete in Triplicate) ��U <br /> a' .. <br /> I al Heath District for permit to construct and/or install the work herein <br /> rApplication is hereby made to the San Joaquin''Loc <br /> l described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or Na. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address Sv Subdivision Name <br /> Owner's Name ., Address Phone <br /> Contractor's Name N License No. Phone rZ _ 91 <br /> r <br /> iL <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION X <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U <br /> J— <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (T^ <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA - CONSTRUCTION SPECIFICATIONS <br /> !] Industrial U Open Bottom-= -0 Manteca !"Dia. of Well Excavation <br /> �` Dia. of Well Casing <br /> U Domestic/Private �Gravel Pack �Tracy g <br /> I Public Other. Delta Type of Casing <br /> L Irrigation <br /> 11 Approx. E] Eastern Specifications <br /> Cathodic Protection Depth <br /> ! Depth of Grout Seal <br /> L7 Geophysical it 1 a Type of Grout } <br /> 4 U Other ( Surface Seal Installed by <br /> r . ,A <br /> Repair Work Done �'' Type of Pump c H.P. State Work Done LJ`� <br /> t Well Diameter N.. Sealing Material (torp y50' <br /> Well Destruction <br /> } — G <br /> ,oro"Depth yC�(j s\ _ Filler 7at�wq� 1 (ELI + so, <br /> n}r - <br /> SEPTIC WO NEW INSTALLATION U REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEP <br /> r T } available within 200 feet.) <br /> Installation will serve: Residence �%,Commercial__e` Other. _ <br /> f Number of living units: Number of bedrooms Lot`size� ' <br /> Character of soil to a,depth of 3 feet: Watertable depth <br /> * ,No. ComW-tinents <br /> ° FI Type/Mfg a Capacity_ <br /> SEPTIC TANK. I! - <br /> Capacity Method'of Disposal <br /> '" w PKG. TREATMENT PLT,. ❑ Type/Mfg <br /> SEWAGE SYSTEM I n Distance to nearest: Well Foundation Property tine <br /> DESTRUCTION <br /> LEACHING LINE I` U No, & Length of lines Total length size <br /> f <br /> Distance to nearest: Well Foundation ProperFILTER BED ❑ , <br /> Ey'Line <br /> SEEPAGE PITS F-1 Depth Size Number <br /> SUMPS U?r <br /> Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS h' ❑ :" <br /> I hereby certify that I have prepared this application and that the work will be don " accordance with San Joaquin county­✓fi <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. - <br /> Home owner or licensed agent's signature cer"tifies the following: "I certify that in the <br /> per <br /> 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 /> F this permit is issued, I shall empToy persons subject to workman's compensation laws of California." <br /> The applica oust cal fo all/required inspections. Complete draw' g�rtTeuerse side. <br /> Date: <br /> Signed X f E_►•v Title: �� - - <br /> i <br /> F DEPARTMENT U5 NLY <br /> -Stk 466-6781 <br /> Application Accepted by�,r- Area <br /> Lodi 369-3621 <br /> Additional! Commen"ts: Manteca 823-7104 <br /> r Date <br /> Pit or Grout Inspection b <br /> e Date 2 ❑ Tracy 835-6385 <br /> Final Inspection by r ft <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazel on Ave., P.O. Box 2004, 5t k., CA 95201 <br /> it <br /> �?ERMITNO.FEE BASE' AMOUNT DUE AMOUNT REMITTED RECEIVED BYDATEINFO <br /> !e <br /> Ff 10/82 500 <br /> EH 13-24 REV.I10/82 .# <br /> 14-26 <br />