Laserfiche WebLink
APPLICATION FOR PERMIT #. <br /> SAN ,1DAQUIN LOCAL HEALTH 'uISTR,ICT �3 <br /> 1601 E. HAZELTON AVE., STOCKTCN, CA PERMIT N0. <br /> Telephone (209) 466-6781 DATE ISSUED 40— <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in,Triplicate) <br /> ermit <br /> l the <br /> Application Thiseppalicationoishmadeninocompliancelw'ithlSan DJ Joaquin County pOrdinance cNo. 549tfor dsewage sorlNo- 1862rherein <br /> forwell/pump <br /> described. Pp <br /> and the Rules a'S e�ula-tiionsof the San Joaquin Local Health District, <br /> Job Address ! (•� 0 Subdivision Name <br /> Address a� Phone <br /> Owner's Name ' - �,7' Phone <br /> Contractor's Name License No. <br /> NEW WELL WELL REPLACEMENT DESTRUCTION LJ <br /> TYPE OF WELL/PUMP WORK: OTHER PUMP INSTALLATION [� SYSTEM REPAIR L]] pROp LINE j <br /> SEWER LINES DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> i FOUNDATION AGRICULTURE WELL <br /> 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial LJ Open Bottom ❑Manteca <br /> Dia. of Well Excavation <br /> U Domestic/Private E]Gravel Pack Tracy Dia. of Well Casing - - <br /> Public [Other Delta Type of Casing <br /> EjIrrigation Approx. Eastern Specifications <br /> j Depth Depth of Grout Seal <br /> kl � Cathodic Protection �- <br /> Geophysical Type of Grout e <br /> ❑Other Surface Seal Installed by <br /> Repair Work Dane Lf Type of Pump <br /> H p State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top.50') <br /> Depth Filler Material (Below 50') <br /> if sewer rmi <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (No septic tank or seepage P°avai <br /> � lableewithinu200cfeet.) is <br /> ! Installation will serve: Residence/� Commercial _ other <br /> ! Number ofds beroom - Lot size , '�iCECS <br /> i Number of living units: �� Water table depth <br /> Character of soil to a depth of 3 feet: Capacity ��,�q No. Compartments <br /> R`sa <br /> SEPTIC TANK $ Type/Mfg Method of Disposal <br /> Capacity <br /> PKG. TREATMENT PLT. [] Type/Mfg ° <br /> Well `� Pro Property Line <br /> SEWAGE SYSTEM Distance to nearest: ld0Foundation /-O <br /> — <br /> DESTRUCTION <br /> LJ Total length/size <br /> LEACHING LINE No. & Length of lines <br /> FILTER BED Distance to nearest: Well <br /> Foundation Property Line <br /> h <br /> De t $ Size ��� Number o <br /> SEEPAGE PITS � p - Property Line <br /> SUMPS L—I <br /> Distance to nearest: Well Foundation <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 personiin such{mannernas to become subjectthat ntohe per <br /> wnrrkmavn� compensationwlaws fof California." <br /> f permit is issued, I shall not employ any p <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whit <br /> this Permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applican us c r a 1 require insp tions. Complete drawing on reverse side, Date: <br /> Title'. �c <br /> signed X <br /> P MENT NLY 466-6781 <br /> Area =-_�_,_ EJ Stk <br /> k Application Accepted y C] Lodi 369-3621 <br /> Additional Comments: l Date ,$ ❑ Manteca 823-7104 <br /> Pit or Grout Inspection by Date _ S_IS3� ❑ Tracy 835-6385 <br /> Final Inspection by r P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: . nvironmental Health Fern <br /> it/5ervices 1601 L. Hazelton Ave., <br /> DATE PERMIT NO. <br /> FEE BASE AMDUNT DUE AMOUNT REMITTED RECEIVED BY II_ <br /> INFO �O> Ll � 3—M <br /> L <br /> 10/82 500 <br /> Eh 13-24 REV. 10/82 <br /> 14-26 <br />