Laserfiche WebLink
rY <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. <br /> 1601 E. HAZELTON AVE., ST,�OCKTON, CA <br /> Telephone,(209) 466-.6781 DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) - <br /> Application is'herebl,CateonoiSh deninocompliancelwHthlSanDistrict <br /> in Countypermit <br /> Ordinance construct <br /> forand/or <br /> sewagesorlNo, 1862work <br /> forherein <br /> well/Pu mP <br /> described. This app <br /> and the Rules and Regulations of the San Jquin Lo 1 alth District. <br /> i� Subdivision Name <br /> Job Address Phone <br /> t Address phone <br /> Owner's Name f <br /> Contractor's Name <br /> License No. <br /> WELL REPLACEMENT DESTRUCTION <br /> TYPE OF WELL/PUMP WORK: <br /> NEW <br /> TYPE OTHER <br /> PUMP INSTALLATION SYSTEM REPAIR PROP LINE <br /> SEWER LINES DISPOSAL FLD, n� <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> FOUNDATION <br /> CONSTRUCTION SPECIFICA IONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Well Excavation 2— <br /> Industrial U Open Bottom Manteca <br /> 113 Dia. of Well Casing <br /> ❑Tracy <br /> Domestic/Private ravel Pack /4 <br /> Public <br /> Other Delta Type of Casing G <br /> Irrigation Approx. Eastern' SpecificationsIle <br /> Depth Depth of Grout Seal <br /> Cathodic Protection r <br /> i <br /> L3 Other Type of-Grout a <br /> U Other Surface Seal Installed by <br /> S s R.P. <br /> State Work Done — <br /> Repar Work Done Type of Pump <br /> Sealing Mat iai itoP 501} <br /> Well "Destruction F-1 Well Diameter Filler Material (Below 50') <br /> ' Depth <br /> REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is <br /> I7.YPEjOF SEPTIC WORK: NEW INSTALLATION L1 available within 200 feet.) L1 <br /> I ` Other -{^ <br /> E Inn'stallation will serve: Residence f Commercial _ Lot size .1 <br /> f Number of living units: Number of bedrooms water table depth 7 <br /> Character of soil to a depth of 3 feet:.. Capacity �� No. Compartments: <br /> fgSEPTIC TANK Type/M Method of Disposal <br /> -Capacity C <br /> PYG. TREATMENT PLT. ❑ Type/Mfg 4K7 <br /> F Foundation Property Line <br /> j SEWAGE SYSTEM Distance to nearest: Well <br /> f DESTRUCTION <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> b Foundation <br /> FILTER BED Distance to nearest: Wela } <br /> Size 1 i Number <br /> SEEPAGE PITS Depth ��-__ E property Line <br /> SUMPS L_1 <br /> Distance to nearest: Welles---�--»Foundation <br /> DISPOSAL PONDS CI 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, state laws, and rules and regulations of the San Joaquin Local Health District.rformance compensation laws of California." <br /> Home owner or licensed agent's signature certifies <br /> such;mannernas to become subject that ntohworrkman� comp of the work for which this <br /> permit is issued, I shall not employ any P 4 <br /> Contractor's hiring or certifies the <br /> s}compensationrlaws ofCalifornia." <br /> of the work for whit <br /> this permit is issued, i s P Mete dra i g o reverse side. <br /> The appli ant mus 11 fo all r ed inspections. Comp 1/' Date: <br /> itle: <br /> 4� <br /> Signed f 466 81 <br /> FORtU ART NI J USE ONLY "�aArea Stk <br /> Applicati Acc ted by /_ _' .- �, - — � Lodi` 369-3621 <br /> f Additional Comments µ {`X Date.-- - --�.Manteca-823-7104. _ <br /> .,- - Pit-cr"Grout-ins ection•b 1�j"racy" 835-6385 <br /> 01 <br /> �_Finahlnspec't`ion'by" "' <br /> Applicant - Return all copies o: Enviranm tal Health Permit/Services 1601 E. Hazelton Ave., P.0. Box PO RMI TSNO.' CA 952 <br /> ------------ <br /> DATE W <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y R gy laS <br /> INFO p,(� � �{�� <br /> r ✓ - <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 _:.- - -.-7- <br /> 14_ <br /> -._2.6_ <br /> _ <br />