Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUiT; LOCA_ HEALTH DISTRICT t¢? / /f� <br /> 1601 E: HAZELTON AVE„ STOCKTON, CA PERMIT NO. (f J _ (c(0� <br /> Telephone (209) 466-6781 • DATE ISSUED b o� <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> M3-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 complian e with San Joaquin County Ordinance No. 549 for sewage or No. 1$62 for well/pump <br /> and the Rules and Regulations L!if he San o qui oc l Health District. <br /> Job Address / r Address Subdivision Name +'�J �c <br /> Phone ® -•129.2-0 <br /> JOwner's Name .C � — ray Phone � a —cSf��— <br /> Contractor's Named License No. <br /> i., call <br /> TYPE 6F-WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U _ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHEpISPOSALRFLD. PROP. LINE ' <br /> DIST ANCE TQ.NEAREST: SEPTIC TANK SEWER LINES 5 <br /> PITS/SUMPS <br /> t ` -AGRICULTURE WELL OTHER WELL V ' <br /> FOUNDATION..- - - � <br /> y F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { <br /> J Industrial --U Open Bottom Manteca Ria, of Well Excavation <br /> t U Domestic/Private—D Gravel Pack [� Tracy Dia. of Well Casing <br /> PublicI II Other Delta Type of Casing <br /> �n +� Eastern <br /> V Irrigate n- Approx. Q Specifications <br /> Cathodic Protection _ V wD2pth ` Depth of Grout Seal <br /> Geophysical rt Type of Grout , <br /> 44 .. <br /> U Other } s �-#� `" Surface'Seal=lnst_al-led by <br /> tee+:.. ,�� . v, <br /> Repair Work Done E] Type of Pump H:P. State Work bone <br /> ! Well:Destruction U Well Diameter Sealing Material (top 50') — �( <br /> Depth Filler Material (Belowtso') cx:) <br /> Co <br /> p <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITIONNo septic tank or seepage pit permitted if public sewer is available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: / Number of b roo Lotlsize <br /> � i Water table depth D <br /> Character of_-soil _to a.depth.-o f-3-.f-eet.: � -- <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Method of Dispospl <br /> �� <br /> Capacity <br /> 'SEWAGE SYSTEM. Distance,tb nearest: Well Foundation _�=Cd-- Property.Line � <br /> DESTRUCTION " <br /> �_ -- Total length/size Q <br /> (LEACHING LINE L�No &`Length of lines 0t- � �f r <br /> ,,.FILTER BED17 Distance to nearest: _ Well <br /> Foundation �9 - Property Line <br /> l <br /> 'SEEPAGE PITS Depth _ Size Numbers _ <br /> Distance to nearest: Well Foundation _f Property Line <br /> ... SUMPS L_I • <br /> DISPOSAL PONDS CI <br /> •I hereby certify that [ 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 ceertifrson1en tuchfman�ernas to become subjectthat ntothe <br /> woprkmans compensa erformance of H onwork <br /> lawsfor <br /> of California." <br /> permit is issued, 1 shall not employ any p <br /> Contractor's hiring or.sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this petor'si"s issued, i shall radonempioy.persons subject to workman's compensation laws of California." <br /> The applicant m call f all equired inspections., Complete drawing qn reverse side. pate: <br /> Signed-X : --. - Title: !!J <br /> ' FOR DEPARTMENT USE ONLY Stk 466-6781 <br /> Applicat Accepted by '�'4" Area <br /> Lodi 364-3621 <br /> Additional Comments: Manteca 823-7104 <br /> Pit or Grout InspectionAb Date <br /> Final Inspection byDate Tracy 835-6385 <br /> Applicant - Return all copies 41 ,?NtalHea�lthp.rmit/Serv�ices 1601 E. Ha elton Ave., P.O. Box 2009, Stk., CA 95201 <br /> DATE PERMIT NO. <br /> FEBASE COUNT DUE AMOUNT REhIITTED RECEIVED BY TE <br /> F IO/82 500 <br /> r EH 13-24 REV. 10/82 <br /> v 14-26 <br />