Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQ61N LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 q Qz <br /> p O�J <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED <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 Regulation of the San Joaquin Local Health District. <br /> Job Addressty <br /> Ix 11zle, Subdivision Name <br /> Owner's Name dress ^,Q,0t_j%Q. Phone <br /> Contractor'sName° icense No. t,, 71096 Phone <br /> o� <br /> TYPE OF WELL/PUMP WORK: NEW WELL IJ WELL REPLACEMENT DESTRUCTION U (� <br /> PUMP INSTALLATION J SYSTEM REPAIR Lf OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial (J Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing <br /> Public [—I Other Delta Type of Casing <br /> V Irrigation Approx. Eastern <br /> F-1CathodicProtection Depth Specifications <br /> Depth of Grout Seal <br /> 1_�Geophysical <br /> Type of Grout <br /> Other <br /> A �B � Surface Seal Installed by <br /> Repair Work Done ED Type of Pump 116,4 ____ H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (tap 50') _ <br /> Depth Filler Material (Below 50') �} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION I_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 /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK L Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: :Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS 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 workmanIs 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X �,,r �r 7 y Title: — Date: � '— <br /> �'—"i EPARTMENT SE ONLY � � <br /> Application Accepted by Area Stk 4fi6-6781 <br /> Additional Comments: Lodi 369-3521 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date "�� ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health 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 /> INFO <br /> -4 LA <br /> -3)21,�13 -3 3-?J� <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />