Laserfiche WebLink
Ih <br /> i <br /> ' APPLICATION FOR PERMIT <br /> SAN JOAQJiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � q b7 <br /> Telephone (209) 466-6781 <br /> DATE ISSUED - <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in T.riplicate) <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 Wel3/pump <br /> and the Rules and Regulations of the San Joaquin Local Heal hhDistrict. <br /> Job Address Qnn5 vision Name <br /> Owner's Nam �� 1 Address 2[jl La -�dc� Phone <br /> Contractor's game �t � License No. !)_ (� �o Phone 13 <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL.REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR L OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK F SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation <br /> Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing <br /> Public Other Delta Type of Casing <br /> Ljlrrigation Approx. Eastern <br /> Depth Specifications <br /> Cathodic Protection <br /> Depth of Grout Seal <br /> 1-7 Geophysical <br /> Type of;Grout <br /> Y U Other Surface Seal Installed by / <br /> Repair Work Done k Type of Pump .cH.P. State Work Donne.&,"a <br /> Well Destruction ❑ Well Diameter# Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: 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 Type/Mfg! Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/MfgI.. Capacity Method of Disposal <br /> SEWAGE SYSTEM Distanc'e'to nearest: Well Foundation Property Line O <br /> DESTRUCTION S <br /> k LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distarcei to nearest: Well Foundation Property Line <br /> SEEPAGE PITS F—j Depth Size Number <br /> SUMPS L—I Distanc'e,to nearest: , W_el.l Foundation Prope�rty,Line.__ <br /> DISPOSAL PONDS s lt <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 applican_mu t w9 for all required inspections. Complete dr ing o reverse side. <br /> Signed X Title: Date: <br /> 1 .r <br /> R DEPARTMENT USE ONLY ff <br /> Application Accepted by AreaEj— [] Stk 466-6781 <br /> ` Additional Comments: ! �] Lodi 369-3621 <br /> Pit or Grout Inspection l Date ,,Manteca 623-7104 <br /> Final Inspection by I OF Date �� Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services Al E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT :D.UE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 <br /> 10/82 500 <br /> 14-26 K. <br />