Laserfiche WebLink
w <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL,HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> ,r I� <br /> (Complete in Triplicate) <br /> I <br /> Application is hereby made to the San 'Joaquin Local Health District for a permit to construct and/or install the work ere862 for'well <br /> /pump <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1 <br /> and the RuI's jd Regulations oftheSan Joaquin Local Health District; <br /> job Address JVrU +�a`A'tS4 �• Subdivision Name. <br /> (' k(�A . Address $At'IG Phone c� <br /> Owner's Name Phone <br /> Contractor's Name ( e JLF License No. <br /> TYPE OF WELL/PUMP WORK: NEWrWELL E] WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION 5Y5 OTHER {J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> OISPOSAL FED. PROP. LINE E <br /> FOUNDATION AGRICULTURE WELL <br /> nom- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom [] Manteca <br /> Dia, of Well Excavation <br /> U Domestic/Private F-] Gravel Pack Tracy Dia. of Well Casing <br /> Public [-! Other; Delta Type of Casing J✓ <br /> V Irrigation Approx. Eastern Specifications <br /> ElCathodic Protection Depth Depth of Grout Seal 0 <br /> Geophysical Type of Grout <br /> Other 5urface_5eal Installed by <br /> H P State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction Lf Well Diameter Sealing Material stop 50') — <br /> Depth Filler Material (Below 50'} k �r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/.ADDITION I (Nor septic tank or seepage piavailableewithinu200cfeete) is C <br /> installation will serve: Residence y Commercial _ Other , c r <br /> Number of bedrooms _3=7 �size C��Ae-e ,l P <br /> Number of living units: - Water table depth <br /> Character of soil to a depth of-3 feet: ;�, <br /> p f No. Compartments <br /> SEPTIC TANK Type/Mfg Ca Type/Mfg <br /> ,�"� 't Capacity � <br /> ' Method of Disposal <br /> PKG, TREATMENT PLT. Type/Mfg " » Property Line <br /> SEWAGE SYSTEM Distanci to nearest: Well Foundation <br /> DESTRUCTION i A6 <br /> No` & Len th of lines; I ) Y Total lenigth/size 00 �1�1L�A� <br /> LEACHING LINE 9 S' 'propert <br /> FILTER BED y Line )WeA C <br /> iDistanf <br /> , ce to nearest: Well —Q - Foundation <br /> SEEPAGE PITS Depth <br /> `Size Number <br /> SUMPS Distance to nearest: Well �_� Foundation- <br /> . Property Line <br /> DISPOSAL PONDS <br /> ' lication}and that the work will be don?n accordance with San Joaquin county <br /> I hereby certify that I.have:prepared this app <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: <br /> olio i ng: to'becomeysubjectthat ntohwopkman� compeWsatilonwlaws�of California.° <br /> Permit is issued, I shall not employ anY P g.. <br /> Contractor's hiring or sub-contracting signature certifies the followin I certify that in the performance of the work for which <br /> this permit is issued, I shall employ ersons subject to workman's compensation laws of California." > <br /> The applicant must call for all requd inspections. Complete"drawing'.on;•re�erse;side. £� 5�8 �5 <br /> ,. •�,,,,,,;w .w;,:r _ Date: <br /> Signed Title: <br /> IfI 1C �7--- lC �..,_ <br /> OR DEPARTMENT USE ONLY .,. Stk 466'6781 <br /> f Area <br /> Application Accepted by Lodi 369-3621 <br /> Additional Comments: 823-7104 <br /> �tie �y <br /> Pit or Grout Inspection by �_, J ��;:Marteca <br /> Tracy 835-6385 <br /> y <br /> Final Inspection by <br /> k Applicant - Return all copies to Environmental Health Permit 1601` E. 'Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> � <br /> FEE BASE AMOUNT . DUE AMOUNT REMITTED RECEIVED BYDATE <br /> PERMIT N0. <br /> � INFO �� � _ -.S: ����.� «.... �7 1!^S/•�S �5..--.��^7.b..��..•..-..•y...-.-»-....,......� <br /> „. --�.-•_.��.-�- .S�, IO oo` � ' � 10!82 500 <br /> r33 <br /> EH 13-24 REV. 10/82 <br /> 14-25 <br />