Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. <br /> 1601 ETelephoneN(209)AVE.�466-678STOCKT01. CA <br /> DATE ISSUED �0 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) Se <br /> l the <br /> rein <br /> Application is hereby <br /> i a'de toithe <br /> San <br /> made iJoaquin <br /> ianca wfithlSan th DJoaquin county istrict for a pOrdinance ermit to cNo. 549tfor dsewage sorlNo. 1862rfor ewell/pump <br /> described. This pp ,. <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Q- Re Q ` C Subdivision Name <br /> Jab Address 3 ����L j <br /> }`. Phone <br /> S��eyy��nc� (L Address 40� Phone -�Zel1 <br /> Owner's Name '�-_=� <br /> License No.. <br /> Contractor's Name tA,' 1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT 7DESTRUCTION <br /> U `� <br /> PUMP INSTALLATION SYSTEM REPAIR I�EWER LINES DISPOSAL FED. PROP, LINE <br />` <br /> S <br /> SEPTIC TANK <br /> DISTANCE TO NEAREST: -_�-�— AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> CONSTRUCTION SPECIFICATIONS <br /> y INTENDED USE TYPE OF WELL PROBLEM AREA _iDia.. of We11 .Excavatitih N <br /> Open Bottom Manteca:—" -= J <br /> ID Industrial U p BottDia. of Well Casing �.----..�-- <br /> Domestic/Private F_j Gravel Pack Tracy <br /> Public <br /> [J Other Delta Type of Casing <br /> r -, •� :� <br /> V Irrigation Approx. Eastern Specifications <br /> Depth Depth of Grout Seal <br /> Cathodic Protection I. ' i <br /> Geophysical <br /> Type of Grout <br /> U Other Surface Seal Installed by _ <br /> Type of Pum H.P. State Work Done <br /> Repair Work Done [} yp p - <br /> Sealing Material (top 50') % <br /> Well Destruction ❑ Well Diameter 1 <br /> Depth Filler Material (Below 50') <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION � (No septic tank or seepage pit permitted if public-sewer,is <br /> Installation will serve: Residence X-. Commercial Other �. <br /> ` Number of�bedrooms Lot size 3 X 30 <br /> Water table depth <br /> j Number of living units: �- , - <br /> f Character of soil to a depth of 3' feet: <br /> Capacity No.-rCompartments <br /> # SEPTIC TANK �j Type/Mfg - `- "'" '*,,Method of Disposal' <br /> 1 .Capacity <br /> PYG. TREATMENT PLT. ❑ Type/Mfg Property Line <br /> r <br /> SEWAGE SYSTEM Distance to nearest: <br /> Well Foundation -�.� <br /> DESTRUCTION -�� <br /> No. &`Length of lines '� - L"t S S S Total length/size <br /> s LEACHING LINE - - Foundation /o Property.Line <br /> f FILTER BED Distance_to nearest: Well f�0 <br /> Size Number <br /> SEEPAGE PITS F-1Depth, Property Line <br /> ' SUMPS Distance to nearest. Well <br /> Foundation <br /> DISPOSAL PONDS <br /> I hereby certifythat <br /> I have <br /> rp epared this <br /> ap <br /> ationsaof the nSan hJoaquat inwLocal ork 1Heall bthdDistrict one in ccordance with San 3oaquin county <br /> f <br /> ordinances, "I certify that in the performance of the work for which this <br /> Home owner or licensed agent's signature certifies the following: <br /> permit is issued, 1 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 signatureons certifies etto workman6l <br /> s � certify a <br /> ompensationlaws ofCalifornit in the aerformance of the work for which <br /> this permit ' issued, <br /> The applic t us call or a re uire <br /> spections. Complete drawin on reverse Date: <br /> Title: <br /> Sign X ' <br /> A NT USE ONLY iso,. Stk 466-6781 <br /> Area -�-� <br /> Application Accepted bye Lodi 369-3621 <br /> Additional Comments: Date < Manteca 823�7-104 <br /> Pit or Grout Inspection by Tracy _835-6385 <br /> DateZ <br /> Final Inspection by P.O. Box 2009, St k., CA 95201 <br /> C Applicant - Return all copies4ta: Environmental th per. 1601 E. Hazelton ve., <br /> AMOUNT REMITTED <br /> RECEIVED BY DATE PERMIT NO. <br /> s <br /> F�FEEBASE AMOUNT DUE <br /> Lis 10/82 500 <br /> � <br /> EH 13-24 REV. 10/82 `I`-1 L (D / <br /> 14-26 <br />