Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN`LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. _ =� `7 <br /> Telephone=(209) 466-6781 / <br /> � PERMIT EXPIRES`1 YEAR FROM DATE I55UED- 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 theRules a d R�gula®ns the San Joaquin Loca] Health District, <br /> Job Address Subdivision Name <br /> Owner's Name ess Phone <br /> Contractor..,'s,Name _ License No, <br /> . x.' Phone <br /> TYPE OF WELL/PUMP WORK:' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION' SYSTEM REPAIR 1 OTHER <br /> DISTANGEO-NEJ4REST:—STTANK.-...---.r--- .SEWER-LI•NES�.` ' " DISPOSAL <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATEONS <br /> Industrial ❑ Open. Bottom [] Manteca Dia. of Well Excavation <br /> -.-�—U �omestic/.priva'te�--�--. elPack—E]-Grav — <br /> � �-Trac y •- Dia:—of-Wel]--Easing ...,�,_. <br /> Public: <br /> (� Irrigation ❑Other. ❑D elta Type of Casing <br /> Approx. Ell, <br /> Eastern <br /> Cathodic Protection Depth . 1 SpecificationsJI <br /> Geophysical . I Depth of Grout Seal <br /> U Other { Type of Grout U, <br /> I € <br /> Surface .Seal Installed by <br /> Repair Work Done �] Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter r ,Sealing Material '(top 501) <br /> Depth De j '' ` <br /> .1 p � Filler Material (Below 50') <br /> TYPE.OF,SEPTIC WORK: NEW INSTALLATION REPAIR ADDIT10N ❑ 4(No septic tank or se6p—age,pit permitted if public°sewer is <br /> r <br /> Installation will serve: Residence available within 200 feet.) <br /> -Co�ninercial Other <br /> Number of living units: — —- iNumber of bedrooms a Lot size <br /> Character of soil to a depth of'3 feet: i Water table depth <br /> SEPTIC TANK 6�fype/Mfg T C Q Capacity _ No. Compartments r� <br /> PKG. TREATMENT PLT. Mf T e 1 <br /> ❑ yP / 9 I Capacity Method of Disposal <br /> SEWAGE SYSTEM ❑ Distance to nearest: We1) <br /> DESTRUCTION Foundation Property Line <br /> _ <br /> LEACHING LINENo. & Length of lines - ' <br /> Total length/size <br /> .-�-- .FLLTER--BED_.[j],_Distance-torn earest:-Wel l Foundation—Property-tine* <br /> SEEPAGE PITS Depth -- Size '.. mbe'� <br /> SUMPS LJ Distance to nearest: Well T� Foundation , Property Line <br /> DISPOSAL PONDS # <br /> f <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 Lqcal Health'•District: <br /> Home owner or licensed agent's signature certifies the following: °I certify thatlin the performance of the work for which this <br /> ermit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." <br /> ctor's hiring or ub-contract' signature certifies the following: "[ certify that in the performance of the work for which <br /> this pe is issued, shall emplo ersons subject to workman'"s compensation laws of California." <br />� Th 7ica t m u r dinti Complete dr g on re,l rse`si `` <br /> Signed itle: C Date: <br /> �~ EP MEHT U ONLY, t s <br /> Application Accepted by _ s Area Stk 46fi-6781 <br /> Additional Comments: i [ ` [ {'°" Lodi 369-3621. <br /> W Pit or Grout Inspection by # Date Manteca 823-7104 <br /> Final Inspection by { ;DateTracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601E�Frz"edton,dleP.D. Box 2009, Stk., CA 95201 <br /> I / ( _! 1 A i.i <br /> FEE BASE AMOUNT ?DUE AMOUNT REMITTED xRECEIVED-BY <br /> INFO DATE PERMIT NO. <br /> EH 13-24 REV. 10/82 <br /> I4-26 I0/82 500 <br /> -. <br />