Laserfiche WebLink
j( APPLICATION FOR PERMIT j k <br /> SAN JOAQUIN LOCAL HEALTH DIST,R1 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <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 OrdinaTe No. 549 for sewage or No. 1862 for well/pump 1 <br /> and the Rules and ReguI ti s of the n Joaquin Lo 1 Heal��t,h/�,,��Dis ct. C{N.`�` xr <br /> Job Address � `SU ivision l/y <br /> Owner's NameJ is <br /> Address Phone <br /> Contractor's NameLicense No. Phone f <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION F-1 <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <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 /> r tic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public F-10ther ❑ Delta <br /> Irri ation Type of Casing <br /> LJ 9 Approx. []Eastern Specifications <br /> Cathodic Protection Depth <br /> Geophysical Depth of Grout Seal O <br /> Other Type of Grout <br /> f`/, Surface Seal Installed by <br /> Repair Work Done�Type of Pum H.P. S State Work Done <br /> Well Destruction F-1 Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U 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 living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Ej Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION Cl <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED F-1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS U 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 employ persons subject to workman's compensation laws oflifornia." <br /> The applican t call f 1 required in pections. Complete drawing on rerer a side. <br /> Signed Title: Date: <br /> 0 EPART ENT USE NLY � y <br /> Application Accepted by Afea / Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date ///������LJ Manteca 823-7104 <br /> Final Inspection by _ Date � L Tracy 835-6385 <br /> Applicant - Return all copies to: vironmental Health Permit/Services 1601 E. Hazelton Av ., 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 10/82 500 <br /> 14-26 <br />