Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAM N LOCAL HEALTH DiSTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT 40. —��O <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM,DA7E 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 Ck <br /> and the Rules andgla-tjngs ofhe San Joaq n Local Heal District. t <br /> Job Address_17ITi! 4!/�i ubdivision Name CJ I <br /> Owner's Nam Address <br /> Phone <br /> Contractor's Name License No, <br /> Phone l <br /> TYPE OF WELL/PUMP WORK: NEW WELL j] WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR L 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 /> J Industrial U Open Bottom F Manteca Dia. of Well Excavation <br /> iU Domestic/Private Gravel Pack { Tracy Dia. of Well Casing f <br /> i] Public jOther ❑ Delta <br /> Type of Casing <br /> I iIrrigation Approx. Eastern \ <br /> I Specifications Cathodic Protection Depth - <br /> �j <br /> k � Geophysical - �.Depth of Grout Seal � <br /> Type of Grout 1 <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EZ��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: 1/ Number of bedrooms Lot sizeJ XQ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. Type/Mfg Capacity 1 �� No. Compartments _ <br /> PKG. TREATMENT PLT. Type/Mfg Capacity _ Method of Disposal <br /> SEWAGE SYSTEM II�� Distance to nearest: Well ��/� Foundations Property Line <br /> DESTRUCTION u 41 moi`-- <br /> LEACHING LINE U No. & Length of lines Total length/size / 7v <br /> FILTER BED Distance to nearest: Well /B Q Foundation _J_jCZ_„___ Property Line T I <br /> SEEPAGE PITS [j 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 employ persons subject to workman's compensation laws of California." <br /> The applicant must all or 11 equir spections. Co ete draws on revers de. } <br /> Signed X tle: _ � � Date: <br /> Application Accepted by USE ONLY Area ;Z Stk<2D <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Lj Manteca 823-7104 <br /> Final Inspection by Date 1_1 3 Tracy 835-6385 <br /> Applicant - Return all copies t Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2069, Stk., CA 95201 i <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 />