Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, g.3 3�,S <br /> Telephone (209) 466-6781 <br /> DATE ISSUED - <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CZA <br /> (Complete in Triplicate) CA <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 witJ San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump ' <br /> and the Rules and Reulations� the an Joaqui Loca Hea15u&�sSorT �a�-t:�.� <br /> Job Address N� L <br /> Owner's Name Addre s o <br /> Contractor's Name License No. S Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTfON-0 <br /> PUMP INSTALLATION SYSTEM REPAIR'S i OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 F-1 Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack �r_1 Tracy Dia. of Well Casing <br /> Public Other Delta <br /> Type of Casing <br /> F, irrigation Approx. Eastern <br /> Cathodic Protection Depth Specifications <br /> 1 Depth of Grout Seal <br /> Geophysical <br /> f, tType of Grout <br /> 17 Other T SurfacerSeal Installed by <br /> R'PairwWork Done Q Type of Pump H.P. State Work Done r '•' <br /> Well Destruction.0 _Well Diameter 9 Sealing Material' (top 50'.) <br /> Dept h - Filler Material (Below 50' %} € <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION U, REPAIR/ADDITION (No septic tank or seepage'pit permitted if public sewer is <br /> �_ ',,� � available within 200 feet.) <br /> Installation will .`Serve: sidence Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a de th of"3 feet: , <br /> p �._ _ „rWater table depth <br /> SEPTIC TANK [j Type/Mfg ' `ti Capacity No. Compartments <br /> PKG. TREATMENT PLT.rType/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION Q. �~ <br /> { <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth . Size Number <br /> €i SUMPS, { a U 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, ss <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, 1.shall not employ any person in such manner as to become subject to workmant 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 is ued, I s 11 employ persons subject to workman's compensation laws of California," s <br /> �IIII The app ust c 1 fo all qu nspections. Complete dr wing or)reverse si e. <br /> s_ ~S3g Title: Dat <br /> til * F P NT USErY <br /> i Application A ce ted by a <br /> Stk - 466-6781 . <br /> f .lt Additional Comments: —Lodi 369-3621 <br /> Pit or Grout Inspection Al Date LJ Manteca 823-7104 1 <br /> k <br /> Final Inspection by Date �} Tracy 835-6385 <br /> w�� <br /> Applicant - Return all copies o: Environmental Health Permit/Services 1601 . Ha elton Ave., P.O. Box 2009, St k., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/$2 500 <br /> 14-26 <br />