Laserfiche WebLink
APPLICATION FOR PERMIT <br />SAN JOAQU'iN LOCAL HEALTH DISTRICT C� <br />1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. - <br />Telephone (209) 466-6781 —u` <br />PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED DATE ISSUED <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. 1862 for well/pump <br />and the Rules and Reg a 'ons ofSan Joaqujrrll�cal Health District. I <br />Job Address 11:I�! Py <br />ubdi isiao—Name %L) G f� <br />Owner's Name Address 'OC I J Phone <br />Contractor's Name License No. d Phone�� f� <br />TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT <br />PUMP INSTALLATION SYSTEM REPAIR <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br />FOUNDATION AGRICULTURE WELL <br />INTENDED USE TYPE OF WELL PROBLEM AREA <br />Fj Industrial U Open Bottom ❑ Manteca <br />Lf Domestic/Private E] Gravel Pack Tracy <br />f7 Public F—, Other F_-1 Delta <br />DESTRUCTION <br />OTHER U <br />DISPOSAL FLD, <br />OTHER WELL <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation ■ <br />O.ia. of Well.Casing` ` <br />PROP. LINE <br />PITS/SUMPS <br />Irrigation Type of Casing i 9 Approx. Eastern Specifications <br />F—ICathodic Protection Depth <br />Depth of Grout Seal <br />Geophysical : j <br />LJ Other } Typerof Grout <br />Surface Seal Installed by I <br />Repair Work Done ❑ Type of Pump. H.P. State Work Done f <br />Well Destruction U Well Diameter R Sealing Material (top 501) <br />Depth ' ..Filler Material (Below 50') t <br />TYPE OF SEPTIC WORK: NEW`INSTALLATIONjy�I REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br />4 ff`` , available within 200 feet.) <br />Installation will serve; Residences KCommercial _ Other � i <br />Number of living units: Number ofbedrooms Lot size <br />Character of soil to a depth of 3 feet: �Q-r�—L Water table depth <br />SEPTIC TANK EJ .Type/Mfg Q 0.4 Capacity 'Z No. �Compartments <br />PKG. TREATMENT PLT. L Type/Mfg Capacity - Method of Disposal <br />SEWAGE SYSTEM • r <br />Distance to nearest: Well Foundation 1 Property Line <br />DESTRUCTION L�1 i <br />l.J <br />N <br />N <br />�a <br />LEACHING LINE <br />No. & Length <br />-of -lines -....,2 .+•+YTotal <br />length/size <br />FILTER BED <br />t <br />Distance to <br />nearest: Well} -Foundation <br />„Pr perty Line <br />SEEPAGE PITS <br />Depth <br />Sized <br />Number <br />SUMPS <br />Ll <br />Distance to <br />nearest: Well Foundation <br />f Property Line <br />DISPOSAL PONDS <br />❑� <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 empigelany person in such manner as to become subject to workman5 compensation laws of California." <br />Contractor's hiring or sub-contr ng s" ature certifies the following: "I certify that in the performance of the work for which <br />this permit is i sued, 1 shall plo rsons subject to workman's compensation laws of California." <br />The applican st cal r r red inspections, Completera ing o reverse ide. <br />Signed X Title: Date: <br />i <br />R DEPARTMENT USE ONLY i <br />pplicatio ted by Area � Stk 466-6781 ) <br />Additional Comments:Lodi 369-3621 <br />Pit or Grout Inspection b Date Manteca 823-7104 <br />Final Inspection by Date L Tracy 835-6385 <br />Applicant - Return all copie to: Enviro mental Health Permit/Services 1601 E. H zelton Ave., P.O. Box 2009, Stk., CA 95201 <br />FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br />INFO <br />EH 13-24 REV. 10/82 � ! 10/82 500 <br />14-26 1�_`-r„i`11it <br />