Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRGCT ! <br /> 1601 E. HA7ELTON AVE., STOCKTON," CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicationishereby 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 /> Jab Address— S liI.Q1''l�iq �, _ Subdivision Name <br /> Owner's Name — L � i.�1>_!��iQ1?yJIFJrs Z/�� Lif/I L c��� � Phone 93/- 3Z1r5 <br /> Contractor's Name Al <br /> icerse No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F-] DESTRUCTION <br /> PULP-INSTALLATION L�� SYSTEM REPAIR OTHER L} <br /> DISTANCE TO NEAREST: SEPTI ANK AF7. SEWER LINES DISPCSAL FLD. PROP. LINE 4 <br /> ) <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF.'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L Industrial U Open Bottom - _R Manteca y. - Dia. of Well Excavation <br /> 'L�7Domestic/Private I <br /> [� Gravel Pack' ""`� Tracy Dia, of Casing <br /> Public Other Delta <br /> Irrigation Type of Casing <br /> � <br /> L� 9 Approx. Eastern <br /> E] Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal ! <br /> Type of Grout <br /> U Other <br /> Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done 9EAv[,/ 1 (Z�� �T�(/ <br /> Well Destruction ❑ Well Diameter ;1.. Sealing Material (top 50') �(j rzV_.NDel <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NE 4IAINSTALLATION Ll REPAIR/ADDITION U (No septic tank or seepage pit permitted .if public sewer is <br /> available within 200 feet.) <br /> Installation will sery e:� 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 j Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Type/Mfg `1 Capacity Method of Disposal r <br /> SEWAGE SYSTEM, Distance to nearest: Well Foundation- r----P-roper-Yy Li.n,e.,.,,_,_� _ <br /> DESTRUCTION <br /> LEACHING LINE,�'" `; ❑ No. & Length of lines Tota length/si <br /> FILTER BED Distance to nearest: Well Foundation ), Property"Liffe <br /> SEEPAGE PITS Lj Depth F Size ) Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line s' <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that fhe work will be done in accordance withj San Joaquin county E <br /> ordinances, state laws, and rules and regulations of theSanJoaquin Local Health District. C� <br /> Home owner or licensed agent's signature certifies the,ohlowing: fyhaf in the performance of the work For which this <br /> permit is issued, I shall not employ any person in such manner as to became subject to workman compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fdllowing: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject toGworkman`,s compensation laws of California." t <br /> The appliWt, 11 for 1 quired inspections. Complete d"rak'ng reverse side. <br /> Signed X Tit le: pg Date: <br /> D ARTMENT'G� LY i . �� �+�C9 <br /> Application Accepted by Area " Stk 466-6781 <br /> Additional Comments: ! 1 ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by } Date L Manteca 823-7104 <br /> -'"T'W�Fina1 Inspection by -6385 <br /> Applicant - Return all copies to: lEnv onmental health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> E <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY " DATE PERMIT NO. <br /> INFO ` ` <br /> i <br /> EH 13-24 REV. 10/82 14/82 500 i <br /> 14-26 <br />