Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQLIP; LOCAL HEALTH DISTRICT <br /> 1602 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 N6. 1862 for wel3/pump <br /> and the Rules andRegulationsof the San Joaquin Local Health District. <br /> .lob Address / eaof Subdivision Name <br /> Owner-'s Name Address 7-Woj Phone <br /> Contractor's Name CA WA71VZ?V& No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> LW <br /> PUMP IN57ALLAT[ON E] SYSTEM REPAIR /-�\ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -J�Q 7-PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial U Open Bottom Manteca Dia, of Well Excavation <br /> �omestic/Private P<ravei Pack ❑ Tracy Dia, of Well Casing <br /> Public CJ Other Delta <br /> IrrigationType of Casing _ PVC /60 , <br /> Depth Eastern Specifications _ f�Q �E,✓ <br /> [ Cathodic Protection P t <br /> Geophysical Depth of Grout Seal <br /> LJ Other Type of Grout t3F N� <br /> —Surface-Seal-Installed"by, - <br /> Repair Work Done`�Wel <br /> ype of Pump H.P. State Work DoneWell Destructionl Diameter _________.,.Sealing-Material {.top 50') <br /> Vt <br /> pth Filler Material (Below 501) <br /> TYPE OF SEPTIC ARK: NEW INSTALLATION ❑ 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 El Type/Mfg r _ Capacity No. Compartments t/> <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS [71 Depth Size Number <br /> SUMPS LJ 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-wh-ch-this a , <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman compensation Taws of California." <br /> Contractor's hiring orub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, shall employ persons subject to workman's compensation laws of California." <br /> The applica us ca for 1 required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> EPARTMENT USE ONLY / <br /> Application Accepted byArea _ ! Stk 466-6781 <br /> Additional Comments: t [] Lodi 369-3621 <br /> Pit or Grout Inspection by Date r" fw--� N­WAanteca 823-7104 <br /> Final Inspection by _ Date Tracy 835-6385 <br /> Applicant - Return all copies to: Envir nmental Health Permit/Services 1601 E. 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. IO/82 10/32 500 <br /> 14-26 <br />