Laserfiche WebLink
APPLICATION FOR.PERMIT <br /> r <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, <br /> Telephone (209)466-6781 <br /> DATE ISSUED <br /> k PERMIT EXPIRES 1­YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) t <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 Address Subdivision Name <br /> Owner's Name 6 Address <br /> Contractor's Name LicPhone <br /> TYPE OF WELL/'PUMP'WORK:- 'NEVJ WELL~ 0- -WELL-REPLACEMENT ❑ - DESTRUCTION <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER .❑j <br /> DISTANCE TO NEAREST: SEPTIC TANK) SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> C <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial 'sL].Open Bottom Q Manteca Dia, of Well Excavation <br /> U Domestic/Private+ Y Gravel Pack Tracy Dia. of well Casing i <br /> j17 Public Other Delta <br /> Irrigation Type of Casing 9 <br /> L_i 9 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 ❑ Type of-Pump H.P. State Work Done P <br /> Well Destruction U Well Diameter_ Sealing Material (top 50') _ -5 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATP_ 1.PA.1"1R'J_A'DDITION U (No septic tank or seepage pit permitted if public sewer isavailable within 200 feet.) <br /> Installation will serve: Residenceomrcial Other <br /> Number of- living units: J Number of bedrooms Lot size - /5�: <br /> Character of soil to a depth of 3 feet: l --.,Water table depth <br /> SEPTIC TANK F-1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity_Method of Disposal <br /> SEWAGE SYSTEM ; <br /> ��••----tt ➢istance to nearest: Well Foundation Property Lina <br /> DESTRUCTION <br /> LEACHING LINE No. &'Length of lines — L4 Q Total length/size Vv <br /> FILTER BED ❑ Distance to nearest: Well €oundation �`� Property 'Line <br /> SEEPAGE PITS Cj -Depth T Size -,?IL -Number � a. <br /> SUMPS Distance to nearest: Well 10 0 oundation 10/J-- _Property Line r � <br /> r— r <br /> DISPOSAL PONDS ❑ ---- -T- -.$�--._a,v„ <br /> I hereby certify that I have prepared this application and that the work-v%ill 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 manrer as to become subject to workman compensat'Ian ']aws of Califarhia'."' �- <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 t call_ or 1 ire inspections. Complete drawing on reverse side. <br /> Signed X <br /> Si - - ,_ _ �' r <br /> 4 Et.Ca. �1 - � Title: Date: <br /> FOR EPARTME E ONL / <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 -7�,41,� Date 4 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Envir m ntal 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 N0. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />