Laserfiche WebLink
. , <br /> r° <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. q-3~ �� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA QQ <br />` Telephone (209) 466-6781 DATE ISSUEDQ <br /> YEAR FROM DATE ISSUED <br /> PERMIT EXPIRES 1 YE , <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. 18b2 far well/pump <br /> and the Rules and Regulations of.the San Joaquin Local Health District. <br /> Job AddressP� Subdivision Name <br /> E Address Phone 7� <br /> Owner's Name Phone <br /> Contractor's Name License No. 3 _ ^ � <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION W <br /> PUMP INSTALLATION C] SYSTEM REPAIR LOTHER EJ ) <br /> SEWER LINES DISPO5AL FLY. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS {� <br /> FOUNDATION �. AGRICULTURE WELL OTHER WELL <br /> TENDED USE TYPE OF WELL PROBLEM AREA *�� CONSTRUCTION SPECIFiCATSONS <br /> IN <br /> '�) Dia. of Well Excavation <br /> Industrial <br /> IJ U Open Bottom []Manteca 'Nj <br /> U Domestic/Private [] Gravel Pack [f Tracy ;{ Dia. of Well Casing ; <br /> Public [S Other D Delta � Type of Casing <br /> Irrigation Approx. Eastern 7 Specifications <br /> Cathodic Protection Depth Depth of Grout Seal ' <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> Ik <br /> Type of Pum H.P, State Work Done n ,Repair Work Done [DYp p -• t. (`f7✓ <br /> { Well Destruction U Well Diameter Sealing Material (top 50'x) <br /> LLL <br /> Depth <br /> I Filler Material (Bel 4P.. <br /> ii <br /> k '�� <br /> 4DDI�T•ON k (Nonseptic tank or~',seepage piaermitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/•.. J '%available within 260 feet.) <br /> Installation will serve: Reside'1_5 ercial _ Other + t <br /> — Z <br /> Number of living units: w.� <br /> Number of bedrooms Lot size <br /> _-.0_- { Water table depth <br /> Character of soil to a depth of 3 feet: <br /> � CapacitNo.bCompartments <br /> SEPTIC TANK fyPe/Mf9 <br /> Capacity i1,,. W3 Method'of Disposal*w <br /> 1 PKG. TREATMENT PLT. Type/Mfg w "' ` � r-,pertY Line <br /> f SEWAGE SYSTEM Distance to nearest'', Well Foundation <br /> DESTRUC710N a"`�. - w � �•°� <br /> . �� Total length/size <br /> LEACHING LINE No`�& LeY'igth aflines ,. t <br /> y� �� 'Property Linef <br /> FILTER BED � Distance,lAo nearest Well !� Fotin�d'ation �D�-w-- <br /> e F'W �.Nu'mher.,. <br /> SEEPAGE PITS Depth _�near_est: <br /> Size <br /> ��r����/ FoundationL7_ P-ro.pe�rty Line �� '� <br /> SUMPS <br /> L Distanc :We]1f7} <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will�rfie done in accordance with San Joaquin county <br /> I i <br /> 1 ordinances, state laws, and rules and regulations of the San Joaquin Lar al Health District. <br /> Home owner or licensed agent's signature certinien suchtKe fmanoer�as-.to becomeysubjectntohwopkmanh ompensation ji-vsfof;California." <br /> --permit-is-issued-, I shall not employ any perso 13 <br /> Contractor's"hi ng-or su'b contract.i.ng a..gnat e certifies the�''followi,ng: the in,the performance of the work far which <br /> this permit is slued,-I-5}� 11 emp19 ec <br /> rson subject to wor an's"compensation'-1aws ofli.fornia.".£ <br /> `� + . ' ' . <br /> The appli a u 1 f all r d i ho s: Comp Lie on'reverse s7•de4 ,s ,� € <br /> ' Title: Date: . <br /> r Signed X <br /> F P ENT USE ONLY ~5Stk 466=5781 ' <br /> Application Accepted by Area ©�_�`-1 ���.;.~�. 1# R � � I <br /> ,TI `� Q Lodiz 369-3621 t <br /> Additional Comments: _ 823-)1'04,- <br /> `,r <br /> i Date / ,Z_ '� Manteea� ~* <br /> Pit or Grout Inspection by e✓ �� �. <br /> Date, ��? L— Tracy N.835-6385 I <br /> 2 10Final Inspection by <br /> e ! <br /> pplicant - Return all copies to: Environmental Health ermit/services 1601 E. Hazelton Ave., P.0, Box'2009 +=Stile CV 952 <br /> EE BRSE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'ND,.' <br /> r <br /> G p <br /> 46, Y 10/82 500 <br /> EH 13-24 RLV. 10/82 { <br /> 14-26 <br />