Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
DAPPLICATION FOR PERMIT <br /> JUN 6 1984 SAN JOAQUIN LOCAL HEALTH.DISTRICT r� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA_ PERMIT NO. <br /> Telephone (209) 466-6781 <br /> r SAN JOAQUIN LOCA. PERMITEXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> HEALTH DISTRI�'�", t. (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 fo"r well/pump <br /> and the Rules and Regulations f the San Joaquin Loc /I Heal District, <br /> Job Address b / 5ubdivli�s✓ion Name <br /> Owner's Name Address o2 `—�� `^ i Phone, ' <br /> Contractor's Name" License No. - - Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER F_�" <br /> :DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LIKE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> .. <br /> " �.�..IN TEN DED-USE TYPE DF WELL -PROBLEM-AREA- CONSTRUC-TIONfSPECIFICATIONS - ' <br /> Industrial Open Bottom Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public ❑Other [] Delta <br /> Type of Casing <br /> ❑ Irrigation Approx. ❑ Eastern <br /> Specification s <br /> I]Cathodic Protection Depth <br /> ❑ <br /> Depth of Grout Seal <br /> Geophysical T <br /> Other Type of Grout <br /> Surface Seal Installed by ti <br /> Repair Work Done Type of Pump H.P. State Work Done 61 <br /> Well Destruction 01 Well Diameter Sealing Material (top 50') _ o <br /> Depth Filler Material (Below 50') <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (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 w <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f? t <br /> PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION Cl <br /> LEACHING LINE F-f No. & Length of lines Total length/size <br /> FILTER BED Distance"to nearest: Well Foundation `"Property"tine <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS IJ 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 . ued, I shall employ persons subject to workman's compensation laws of California." 2 <br /> The applic mu 1 or u' a in a ion . omplete drawing,on reverse side <br /> J <br /> Signed X itle: / Date: <br /> ARTME T USE LY <br /> Application Accepted by e5frea" ❑ Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection Date Manteca 823-7104 <br /> Final Inspection by , Q 1A_4L-r— Date Tracy. 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 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 10/82 500 -� <br /> 14-26 -. <br />