Laserfiche WebLink
- ti • <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT ExPIREs 1 YEAR FROM DATE ISSUED TT���� <br /> (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 in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of th ,San Joaquin Local Health District. <br /> Job Address ,Z - Subdivision Name <br /> Owner's Name iF _Address Phone <br /> Contractor's Name License No. Phone3_4 <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ (� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> v� <br /> 17 <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation _ r <br /> LJ Domestic/Private Gravel Pack Tracy Dia: of Well Casing _ <br /> Public �j Other El Delta Y <br /> Type of Casing <br /> Lj Irrigation Approx. Eastern Specifications _ <br /> Cathodic Protection Depth <br /> Geophysical Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done � <br /> Well Destruction F-1 Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank o'r seepage pit permitted if-public sewer is <br /> available within 200 feet.) <br /> Installation will serve: ResidenceL_/ Commercial-. Other -0 1 <br /> Number of living units: Number of bedrooms _3 Lot sizey�"•^� <br /> Character of soil to a depth of 3 feet: Water table depth _ <br /> SEPTIC TANK Type/Mfg 6_6 r,( L Capacity.[70 No. Compartments 1 �„ <br /> PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of'Disposal' <br /> SEWAGE SYSTEM- Distance to nearest; Welli Foundation Property Line <br /> ' <br /> OESTRUC•TION .r. � w� _.� - - -• <br /> LEACHING LINE No. 8 Length of lines ••I wr Total length/size ( C) <br /> FILTER BED E] Distance to nearest: Well J&D I Foundation Property Line <br /> SEEPAGE PITS Depth aT Size W V <br /> Number <br /> SUMPS U Distance to nearest: Well I Faundatlon _ Property Line 7Q <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 pertondin such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contra ing signature certifies'tfie'folloWin'g':-"I certify that in the pe formance of the work for which <br /> this permit is issued, I sh 1 loy persons subject to workman's compensation laws of California " <br /> The applicant cal equired inspections. Complete drawi.n�g,on reverse side. <br /> Signed x Title:j i:�l�C Date: <br /> FOR DEPARTMENT USE-ONLY App cation Accepted by - Area a �Stk 466-6781 ' <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspectio Y - Date Manteca 823-7104 <br /> Final Inspection by Date L7 Tracy 835-6385 <br /> Applicant - Return all copiffs to: En ironmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> s .. �. . <br /> INFO � � ti B bra � 0 3� J f <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />