Laserfiche WebLink
APPLICATION FOR PERMIT! <br /> SAN JOAQLiN LOCAL HLAIL H DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephane.Y(209) 466`6781 PATE ISSUED <br /> PER6PlT,FXPIRES. I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br />�I .r <br /> n'Locel Health District far a permit to construct or sew install the work herein <br /> Application is hereby made to the San Jo qui <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 far sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> t 41 0 111 CAubdivision N e <br /> Jah Address w ,��� <br /> Address Phone <br /> Owner's Nam �, ol3iR���111 1�s <br /> Contractor's Nam -MV�f� Lse No. (, �p Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [ DESTRUCTION <br /> PUMP INSTALLATION- IX SYSTEM REPAIR D OTHER ZI r <br /> j *^~� SEWER LINES DISPOSAL FLD. PROP. LINE ) <br /> DISTANCE TO NEAREST: SEPTIC TANK _ •- �I <br /> FOUNDATION AGRICULTURE WELL O HER WELL �� PITS/SUMPS <br /> , T <br /> -3NTFNDEO JSE TYPE -WELL- �PROBLEM�AREA - CONST•RUCTI-O SPECIF•I•CATII3NS--- ^^ <br /> Industrial U Open Bottom- Manteca } Dia. of Well Excavation <br /> Domestic/Private Gravel Pa k• Tracy Dia. of Well Casing d7 <br /> Public �IOther Delta Type of Casing G <br /> Irrigation Approx.: Eastern Specifications ✓`s, <br /> /u Cathodic Protection Depth x Depth of Grout Seal �1 <br /> �., <br /> Geophysical Type of Grout � <br /> Otr R Surface Seal Installed by <br /> he <br /> / : <br /> State Work Done <br /> Repair'Work Done Type of Pump H.P: -:57 - <br /> Well Destruction Well Diameter Sealing Material (top 50`) — <br /> .•i.r..�---•'-ate- <br /> Depth FillerFMaterial (Below 50') <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION LI REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public-sewer is <br /> III available within 200 feet.) <br /> Installation will serve: Residence ., Commercial Other 1 <br /> Number of living units: Number of bedrooms Lot size <br /> Character of sail to a depth of'3 feet: <br /> Water table depth <br /> _ Np. Compartments <br /> SEPTIC TANK CI Type/Mfg Capacity <br /> I Capacity Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg ' <br /> SEWAGE SYSTEM o -Distance to,nearest: Well Foundation Property Line <br /> DESTRUCTION 5: - <br /> I LEACHING LINE U No. &.Length-of-lin s� Total length/size <br /> nearest; Well Foundation Property Line <br /> FILTER BED I,'Distance to <br /> SEEPAGE PITS ❑1 Depths r f w5 Number <br /> SUMPS U <br /> Distanto nearest: Well Foundation Property Line <br /> ce <br /> DISPOSAL PONDS �I <br /> 4 <br /> f I hereby certify that I have prepared this­ ion 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 LocalYHealth District. <br /> Home owner or licensed agent's signature certifies the following "I certify that in the Qerformance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmanK compensation laws of Californiac <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*applicant must call for all required inspections. Completed a ng ons reverse Date: <br /> Signed X Title: <br /> F DEPARTMENT SE, IN _ff rea b / Stk 466-6781 <br /> Application Accepted by,A4 I Lodi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> 1t.i�r Gr nspection by Date Tracy 835-6385 <br /> Final Inspection by Date ' _' <br /> Applicant - Return all copies to: Environmental He th Permit/Sera ces 1601 E. Hazelton'1�ve. 95201 <br /> , P.O. Box 2009, Stk., CA <br /> DATE PERMIT NO. <br /> FEEBASE AMOUNT DUE AMOUNT REMITTED �RECEIVED By <br /> f INFO (J <br /> + 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />