Laserfiche WebLink
r <br /> APPLICATION FOR PERMi <br /> SAN JOAQUiN LOCAL,HEALTH DISTRICT f� <br /> 1601 E. HAZELTON AVL., STOCKTON CA 1 ERhSIT N0. �7U�✓ <br /> Telephone (209) 466-67BI S*q PATE ISSUED 3 <br /> PERMIT EXPIRES 1�YEAR FROM DATE 1 !/'! <br /> # (Complete in-Triplicate) � . <br /> t <br /> Application is hereby made to the San Joaquin Loca V Health District-for a permit to construct an /or insta]1 the-.work herein <br /> described. This application is made-:in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulati ns of the'San Joaquin local Health District.- <br /> f � <br /> Job Address Subdivision Name <br /> ` Phone �n �^ �� <br /> Owner's Name Address,/_33. <br /> Contractor's Name <br /> License No. (u Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT,/ DESTRUCTION <br /> Cll r <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER jJ <br /> DISTANCE TO NEAREST- SEPTIC TANK SEWER BINES DISPOSAL FLD. PROP. LINE ` <br /> FOUNDATION AGRICULTURE'WELL OTHER WELL PITS/SUMPS ` <br /> INTENDED USE TYPE OF WELL PROBLEM ARLA`— . CONSTRUCTION SPECIFICATIONS - -} <br /> Industrial U Open bottom-'—--Manteca Dia. of Well Excavation - <br /> �- - -- - <br /> �Domestic/Private Gravel Pack Tracy Dia. of Well Casing E <br /> Public FjOther Delta Type of Casing <br /> Lj Irrigation _Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> 0 Other Surface Seal Insn/t�alled <br /> Repair Work Done Ft Type of Pump 4 f H.P. State Work Done <br /> Well Destruction.0 Well Diameter Sealing Material (top. 50') <br /> Depth Filler Material (Below 50') # f <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L[ REPAIR/,ADDITION j 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 /> '} Water table depth <br /> Character of',soil to a depth of:3 feet: <br /> :.i , Capacity No. Compartments <br /> SEPTIC;TANK: Type/Mfg <br /> Capacity Method of Disposal <br /> ,,PKG. TREATMENT PLT. Type/Mfg <br /> SEWAGE SYSTEM �. Distance to,.nearest: Well Foundation Property Line <br /> r' 'DESTRUCTION <br /> Total length/size <br /> LEACHING LIN�,�° U No. & Lei gth of lines <br /> FILTER BEf) - Distance tohearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> Distance to nearest: Well Foundation Property Line -� <br /> SUMPS LI .. <br />!� DISPOSAL PONDS - --.L- ­ -t� <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, .s tate 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 applica us call fo l required ins ections. Complet rawing on reverse side. pate: ! <br /> Signed x It-Ti tl e: <br /> FOR EP TMENT USE ONLY D4— Sitk 466-6781 <br /> Application Accepted by a �` <br /> 0 Lodi 369-3621 <br /> Additional Comments: f �v/ Manteca 823-7104 <br /> Pit or Grout Inspection by Date U <br /> l -= pate �.2J—�J f0 Tracy 835-6385 <br /> Final Inspection by95201 <br /> Applicant - Return all copies to: 'Environmental Health Permit/Se'rvices 1601 E. Hazeltoh,,Ave., P.O. Box 2009, St k., CA <br /> FEE BASE AMOUNT DUE ' AMOUNT REMITTED • RECEIVED 8Y DATE PERMIT N0. <br /> INFO n 10 <br /> 1D/az 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 l <br /> { <br />