Laserfiche WebLink
APPLICATION FOR.PERMIT ; <br /> SAN JOAQU'iN LOCAL HEALTH DISTRICT �] r <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. <br />,- Telephone (209) 466-6781 <br /> • PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED DATE ISSUED 'g a, <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 the Rules a d R g 1 tions ,th San J aquin.Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name Address <br /> a <br /> Phone <br /> Contractor's Name L<�,E . <br /> se No <br /> Licen . <br /> Phone `c}. <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DIS TRUCTION F } <br /> PUMP INSTALLATION SYSTEM REPAIR �` OTHER LJ <br />' DISTANCE TO NEAREST:.SEPTIC TANK _ SEWER LINES DISPOSAL FED. PROP. LINE <br /> FOUNDATION_ AGRICULTUREWELLOTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom [] Manteca Dia. of Well Excavation <br /> U Domes esticc/Private Gravel Pack Lj Tracy Dia, of Well Casing <br /> Public �j Other Del-«- ta._. <br /> irrigation Type of Casing W + <br /> 9 Approx. Eastern <br /> [Cathodic#Protection Depth x f Specifications i <br /> Depth of Grout Seal <br /> ❑ Geophysical i <br /> U <br /> _ Other c <br /> Type of Grout L <br /> � r �+"r F"'`,` .. .- ._ <br /> } Surface Seal Installed by r <br /> Repair Work Done [] Type of Pump # H.P.3a State Work Done <br /> Well Destruction U Well Diameter ISea iing .Mater ial'(top-50') <br /> Depth } Filler.Material (Below 50') <br /> TYPE OF-SEPTIC WORK: NEW INSTALLATION — REPAIR/ADDITION ? 1qJ <br /> _ PLf'� �� (No septic tank or seepage�.pit permitted if public sewer is � <br /> } E available within 200 feet.) <br /> Installation will serve: Residenc Commercial;_ Other i <br /> e <br /> Number of living units: Number-of bedrooms — Lot size <br /> � i <br /> Characterof soil to adept of 3 feet: Water table depth. <br /> SEPTIC TRNKj �j Type/Mfg 1 Capacity No. Compartments <br /> I <br /> PKG. TREATMENT PLT. Type/Mfg ' { Capacity Method of' Disposal <br /> SEWAGE SYSTEMDistance to nearest: Well Foundati.on- ..Property Line # <br /> DESTRUCTION - s k <br /> LEACHING LINE U No. & Length of lines Total length/size } <br /> FILTER BED Distance to nearest: Well"` Foundation Property Line <br /> SEEPAGE PITS Depth Size Number S <br /> SUMPS i � Distance to nearest: Weil Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this�application;and that the work--wi-11, be done in accordance with San 'Joaquin county <br /> ordinances, state laws, and rules and regulations-of 6e'Sa_6* ,loaquir•-L6cal Health District. <br /> Home owner or licensed agent's signature certifies:the follii9ing.-L"I certify'that it .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 s compensation -laws of California." } <br /> Contractor's hiring o sub-con cting'sighature certifies the following:'•"I'certify`that in the performance of the work for which <br /> t it'i issued I shall em loy pers6ns subject to workman's compensation laws of California." <br /> T lican s ca .1 1 r qui i ctions. Complete dr ng on°r ers <br /> Sig Title: Date: <br /> ( FO EP MENT USE ONLY <br /> Application Accepted by �W� Area Z <br /> �5tk 466-67 <br /> Additional Comments: .- s/Ze 4 �� [� Lodi 369-3621 j <br /> 1 <br /> Pit or Grout Inspection by ate _ Manteca 823-7104 <br /> Final inspection by Date � ❑ Tracy- 835-6385 f` <br /> Applicant -Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 Stk., CA 45201 - <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO ' <br /> EH 13-24 REV, 10/8243-P-4 .1 �( l 10/82 500 <br /> 14-26 -` `� r <br /> i I <br />