Laserfiche WebLink
Pi <br /> APPLICATION FOR PERMIT u� <br /> SAN JOAQUIN LOCAL HEALTH 1 T ' C <br /> 1601-E. HAZELTON AVE., STOC T CA #, � l �� PERMIT NO, <br /> Telephone (209) 466.-67 Ys f��i <br /> PERMIT EXPIRES 1.YEAR FROM DATE ISSUED . L D� � DATE ISSUED L4 <br /> (Complete in Triplicate) <br /> i, Tom' <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_ J 'j S `r Q l Subdivision Name <br /> Owner's Name 137��J�. ,Qne.rn.x deo' j- Address /769 Y21 u ,,� gyp_ � ;� _ Phone <br /> Contractor's Name License No, Phone 6 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �l <br /> IJ lndustrial LL U Open Bottom -Q Manteca-"- �`Di of Well'Excavation'AT- '' - '` -- '- <br /> s <br /> Domestic/Private F_j Gravel Pack Tracy Dia. of Well Casing <br /> 17 Public Other ' Delta <br /> Type of Casing <br /> L, Irrigation Approx. Eastern <br /> Cathodic Protection <br /> Depth Specifications <br /> Depth of Grout Seal <br /> 1-1 Geophysical Type of Grout <br /> U Other i <br /> Surface Seal Installed by <br /> 'Repair Work Done Type of Pump H.P. _3 State Work Done ,e,4v <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/.4DDITION J (No septic tank or seepage pit permitted if public sewer is <br /> f available within 200 feet.) I <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms Lot size ry , <br /> Character of soil to a depth of ,3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg1 Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/MfgCapacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION it <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance,to nearest: Well Foundation Property Line } <br /> r+ } <br /> SEEPAGE PITS ❑ Depth A Size Number <br /> SUMPS L_I Oistanceito nearest: Well foundat'iorn­ —t=Proper-ty-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 workman 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, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant most call for all required inspections. Complete drawing on reverse side. �7 <br /> Signed X j.w �iwµ r� 1 n tle: Date: <br /> �DR�TMENT 0 <br /> Application Accepted by 'Q 7 Area Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by // Date L Manteca 823-7104 <br /> Final Inspection by t` <.� Cc c, Date �_ ri-�rJ L 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 /> it <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> -0 1 Lt <br /> LH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br /> }i <br />