Laserfiche WebLink
I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUi?! LOCA! i.PEALT. DISIR c�,'� � <br /> 1501 E. NAZELTON AVE., STOCKTON%, ERMIT N0, �{j ly-S 7 <br />� Telephone (209) 465-6781P: �"--��TE <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ISSUED <br /> ®����� fi <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 the San Joaquin Local Health District, <br /> Job Address �,{/ ['VA 1'L Subdivision Name <br /> Owner's Namedrol'. t� Address Phane <br /> Contr or's ame ?. 1 .11License No. Phone <br /> gk= dab <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATIONr SYSTEM REPAIR L7 OTHER U <br /> DISTANCE 10_NEAREST:_SEPTIC TANK ,.9 _ SEWER.LINES_ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .w <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation r <br /> M�omestic/Private Irave9 Pack Tracy Dia. of Well Casing <br /> Fubl ic Other Del to <br /> F, Irrigation / I Type of Casing <br /> L5_- Approx. Eastern <br /> ❑ Cathodic Protection Depth Specifications � d <br /> Geophysical <br /> Depth of Grout Seal 1 <br /> T I Other I Type of Grout y, p I t <br /> / rrrY Surface Seal Installed by <br /> Repair Work Dane Type of Pump H.P. State Work Dane VV <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) V 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other 911N <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a=depth of 3-feet: Water table depth <br /> SEPTIC TANK, x a <br /> - D Type/Mfg -;,. Capacity _ No. Compartments ..� <br /> PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal <br /> DESTRUCTION w <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line =, <br /> LEACHING LINE jJ No. & Length of lines Total length/size R1 <br /> FILTER BED Distance to nearest: Well Foundation Property Line f� <br /> SEEPAGE PITS n Depth { Size Number <br /> SUMPS L_1 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 workmant compensation laws of California." a <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.." i <br /> The applican u call r a r uired inspections. Complete draw' g on reverse side. <br /> Signed X �USE <br /> r� <br /> Date: <br /> P LY j ft7y <br /> Application Accepted by�/, Area / [] Stk 466-6781 <br /> Additional-Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by to , Date Tracy 835-6385 <br /> Applicant - Return all copies to;_. E vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> INFO PERMIT NO. I <br /> • ca o o/� 5?L1 <br /> EH 13-24 REV. 10/82. ` 10/82 500 <br /> 14-26 <br />