Laserfiche WebLink
.rJ <br /> APPLICATION FOR PERMIT <br /> % - -�1- <br /> �j�.�—y� lr011 SAN JOAQUiIr' LOCAL HEALTH DISTRICT `Q <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> C,,Q, Telephone (209) 466-6781 DATE ISSUED <br /> 1� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> F (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 it compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and RegiLlations�of the San Joa uzr Local Health District. <br /> •Job Address -:P0 Subdivision Name <br /> Owner's Name &dress �' Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION LJ <br /> PUMP INSTALLATION SYSTEM REPAIR [J OTHER 7-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE OC) it <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } } <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IJ Industrial U Open Bottom Manteca Dia.- of Well Excavation <br /> O <br /> Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ' <br /> 17 Public Other Delta Type of Casing ' <br /> 71 Irrigation Approx. Eastern Specifications <br /> ❑ <br /> Cathodic Protection Depth Depth of Grout Seal ' <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> I <br /> Repair Work Done [J Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION J (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: Waster table depth <br /> SEPTIC TANK Cj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM D' tance to nearer Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size V <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS L1 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 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 persons subject to workman's compensation laws of California." <br /> The applicant wust call for al required inspections. Complete drawing on reverse side. <br /> Signed -X Title: Date: <br /> D T NT U NLY <br /> Application Accepted by Area ,�_._ �tk 466-5781 <br /> Additional Comments: [� Lodi 369-3621 <br /> Pit or Grout inspection + Date L] Manteca 823-7104 <br /> Final Inspection by Date �'3-�`�� Qp, L7 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Atl P.O. Box 2009, St k., CR 95201 <br /> FFEE _ <br /> BASE AMOUNT DUE AMOUNT REMITTED RECEIVEDBY DATE PERMIT&NU. <br /> 10/82 500 <br /> EH 13-24 RFV. 10182 ` <br />