Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Q <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. -5�2r- DrOA <br /> Telephone (209) 466-6781 q <br /> DATE I55UED �Q"a��(13 <br /> PERMIT EXPIRES 1 YEAR FROM 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 Regulations of the San J uin Local ea District— 5 <br /> Joh Address f Subdivision Name <br /> Owner's Name Address / one �}' 3:.Z <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL./PUMP WORK: NEL! WELL J LL REPLACEMENT DESTRUCTION I�} <br /> PUMP INSTALLATION � STEM REPAIR-. OTHER U _ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION q M AGRICULTURE WELL OTHER WELL PITS/SUMPS k 1 <br /> INTENDED USE TYpE.OFF WELL _ PROBLEM AREA _ CONSTRUCTION SPECIFICATIONS <br /> I ndustrial en ottom Manteca Dia. of Well Excavation !r <br /> _ttic/Private • []Gravel Pack Tracy Dia. of'Well Casing 7/? r I <br /> 1-1 Public F-1 other Del to Type of 'Casing <br /> I� Irrigation Approx. E] Eastern Specifications rt <br /> Cathodic Protection Depth Oepth.of Grout Seal �Q <br /> ❑Geophysical a „T Type,of Grout <br /> a'U Other ' <br /> w � i Surface Seal. Installed by 1 <br /> 'Repair Work Done ,Type of Pump H.P. State Work Done f" <br /> Well Destruction �WellyDiameter Sealing Material (top 50') <br /> { Depth Filler Material (Below 50') <br /> f• ! TYPE OF SEPTIC WORK: NEW INSTALLATION L_I REPAIR/ADDITION j J (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> x Installation wil Vserve: Residence Commercial _ Other <br /> i <br /> ` Number of N ving+units: "' 'Number of bedrooms Lot size <br /> �. tr Character of soil to a •depth of 3 feet: Water table depth <br /> SEPTIC TANK '�i U Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PL-T.: E] ' Type/Mfg., Capacity Method of Disposal <br /> SEWAG£ SYSTEM Distance�to nearest: Well —.Foundation Property Line <br /> DESTRUCTION El ` f <br /> -. <br /> LEACHING LINE � U No. & Le —'Total length/size <br /> gth of lines ` `' i <br /> rRILTER BED Distance%to nearest: Well r Foundation n Property <br /> Line <br /> ` <br /> SEEPAGE PITS [j j Depth Size Number <br /> v <br /> SUMPS'� L-1 t Distance to nearest: Well Foundation Property Line <br /> 4 DISPOSAL PONDS ❑ �' , r -' <br /> ]';hereby certify that I have prepared this application and that the work will he 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 /> tractor'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 applicant a for all required inspection mplete'.drawing on reverse side. <br /> Title: <br /> Date: <br /> Signed K ����`��� <br /> FOPART T USE ONLY Stk 66-6781 <br /> Application Accepted by �/� Area <br /> Additional Comments: [ 369-3621 <br /> Lodi <br /> Pit or Grout Inspectio f by Date Manteca 823-7104 <br /> Final Inspection by — ❑ Tracy 835-6385 <br /> Applicant - Return all copies o: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> =INFO <br /> AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE .Q PERMIT N0. <br /> Q��r L/ 1 ��— <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 } <br /> ok <br /> 14-26 <br />