Laserfiche WebLink
is s• A"114 <br /> APPLICATION FOR PERM,T <br /> SAN JOAQU';" LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 3 <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 compliarce with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin L al Health District. <br /> Job Address yt Subdivision Name y <br /> Phone <br /> Owner's Name Address44 061�0 <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP kRK-:t% ;NE4J WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP'SNSTALLATlON-Ur '^SYSTEM-REPAIR OTHER U <br /> SEWER LINES DISPOSAL FLD. Q d (PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK I <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 41 <br /> j rr <br /> Industrial U Open Bottom Manteca Dia. of Well ExcavationtjP <br /> lomestic/Private Gravel Pack ElTracy Dia. of Well Casing u <br /> { Public Other Delta Type of Casing <br /> Li Irrigation C1Q- Approx. Eastern Specifications <br /> { <br /> [:]Cathodic Protection Depth Depth of Grout Seal ftr� <br /> Geophysical Type of Grout <br /> LJ Other } ` Surface Seal Installed by +.y ^� <br /> Repair Work Done E] Type of Pump R7'Ll H.P. 3 i State Work Done <br /> Well Destruction U Well Diameter Sealing Maternal (tap 50') [" <br /> Depth Filler Material (Below 50') I^Uhl <br /> TYPE OF SEPTIC WORK: 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 t !1 <br /> Character of soil to a depth of 3 feet: 3Jx" Water table depth (��f <br /> SEPTIC TANK Type/Mfg <br /> { Capacity No. Compartments GIN <br /> PKG. TREATMENT PLT. [1 Type/Mfg ^ j `'.' Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well' Foundation Property Line <br /> DESTRUCTION ` <br /> LERCHING LINE U No.T& Length of lines �`%:. Total length/size <br /> f FILTER BED Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS [j Depth <br /> Size Number <br /> I SUMPS Distance to nearest: Well Foundation Property Line <br /> j DISPOSAL PONDS <br /> p <br /> I I hereby certify that I have prepared this application and that the 'work will be done in accordance with San Joaquin county <br /> I ordinances, state laws, and rules and regulations of the San Joaquin`�Local Health District. <br /> I 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 person sub' ct to workman's compen tion laws of California." <br /> A— O}e drawing n ever 'de. <br /> The applicant must f a1 q e <br /> Date: <br /> Signed X <br /> F R DEPARTMENT USE ONLY F <br /> Stk X466-6781 <br /> Application Ac p d by <br /> Area <br /> Lodi -369-3621 <br /> i * Additio ments: <br /> Pito 'inspection <br /> Date 'Mantecat8P'_7104 <br /> Final Inspection by <br /> r Date � i7E] Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. H zelton Ave., P.O. Box 2009, Stk A 95201 <br /> FEE BASE AMOUNT DUE ..- .. .AMOUNT,RFMITTED�-� + `RECEIVED BY M- �,DATL PERMIT N0.__ �` <br /> ... INFO' _ JF <br /> -7 1979 <br /> 10/82 SOD <br /> t EH 13-24 REV. 10/82p� <br /> 14-26 <br />