Laserfiche WebLink
` APPLICATION FOR PERMIT <br /> SAA JOAQUiN LOCAL HEALTH (ISTRICT,, a <br /> F E 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � 1PLO <br /> Telephone (209) 466-6781 ' <br /> Y DATE ISSUED <br /> ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k <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 1 <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 Sa Joaqui cal Health District. <br /> Job Address [3� Subdivision Nanie <br /> Owner's Name Address W Phone '{ <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENTDESTRUCTION OO <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER (JI) <br /> W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE l <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F I Industrial U Open Bottom [] Manteca Dia, of Well Excavation <br /> U Oomestic/Private F-1 Gravel Pack ❑ Tracy Dia, of Well Casing <br /> Public F-1 Other Delta Type of Casing F <br /> Li Irrigation Approx. Eastern t <br /> ❑ Cathodic Protection Depth Specifications <br /> Geophysical <br /> Depth of Grout Seal <br /> Other Type of Grout O <br /> Surface Seal Installed by a <br /> Repair Work Done [:] Type of Pump H.P. State Work Done , <br /> Well Destruction U Well Diameter Sealing Material (tap 50') _ F <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION J (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: ,r Number A bedrooms. r.� ~' -Lot size= (ly.� Q # <br /> Character-of soil to'a-depth of 3 feet: Water table depth SC�� <br /> SEPTIC TANK Type/Mfg tL Capacity 'No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well i } - Foundation Property Line SC/- ; <br /> DESTRUCTION El <br /> LEACHING LINE U No. & Length of lines Total length/siz <br /> FILTER BED Distance to nearest: Well FoundationProperty Line { <br /> r <br /> SEEPAGE PITS F-1 Depth Size Number <br /> .SUMPS L Distance to nearest: Well Foundation Property Line { <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have <br /> 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 Cal.ifornia," <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 /> s <br /> The applica ust call for all required inspections. Complete d ing an reverse side. <br /> ��/rYdlir "~ .� <br /> Sign X 7- Title: Date: i <br /> 3 � TMENT USE ONLY �` <br /> A"li tion Accepted b �1� Area v 1 Stk 466-6781 <br /> Additional Comments: [] Lodi 369-3621 wa <br /> Pit or Grout Inspection b Date ❑ Manteca 823-7104 <br /> Final Inspection by Date 7�� � Tracy 835-6385 <br /> Applicant - Return all copies to:, q vir men Health Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 47 u4f <br /> EH 13-24 REV. 10/82 J�, 10/82 500 <br /> 14-26 I �j�, C <br />