Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQLiN1 LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. _��t b <br /> Telephone (209) 466-6781 DATE ISSUED —7 <br /> PERMIT EXPIRES I 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 Joaquin Local Heal h District. 1 <br /> Job Address 7f�� Subdivision Name <br /> y��1nPhone ~ <br /> Owner's Name /y/�y� ��I[��� LJ Address <br /> 4jAt0&JbQ 2— <br /> Contractor's Name <br /> License.No. 4910;*3 _ Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL C] WELL REPLACEMENT D- DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U <br /> DISPOSAL FL➢. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES �— PITS/SUMPS <br /> FOUNDATION `: AGRICULTURE WELL �r OTHER WELL <br /> INTENDED USE TOOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ii IJ Industrial U Open,Bottom Manteca Dia. of Well Excavation <br /> k U DomesticlPrivateGravel Pack Tracy Dia, of Well Casing <br /> Public [] 0 ier Delta Type of Casing <br /> ga <br /> V Irrition it Approx. Eastern Specifications <br /> ❑ Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> i <br /> LJ Other Surface Seal Installed by <br /> Repair Work Dane EJType of Pump H.P. State Work Done — v <br /> r <br /> Well Destruction Well Diameter ��� Sealing Material (top 50') <br /> Depth 7, Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No Septic tank or seepage p}availableewithid if nu200 feet.blic ) 's <br /> Installation will serve: Residence N. Commercial: Other <br /> I Number of living units: ,I.. Number of'bed roorls Lot size <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> f1 SEPTIC TANK ❑ Type/4g Capacity No. Compartments V <br /> PKG. TREATMENT PLT. [—I Type/Mfg Capacity Method of Disposal S <br /> b <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION `I <br /> LEACHING LINE U No. &j Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS �� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C� <br /> _.� <br /> 1 hereby certify that 3 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 /> 3 Home owner or li sed agent'sfsignature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issue I Shall not employ any p on in such manner as to become subject to workman§ compensation laws of California." <br /> Contractor's r g or sub-contracting si ature certifies the following: "I certify that in the performance of the work for which <br /> this permit i sued, 1 shall employ p sons subject to w�rki�nalnl'S compensation laws of California." <br /> The appli t 11 for 1 requi insp ions. Coman reverse side.. ��TitDate: <br /> FOR DEP TfENT USE ONLY k 466-6781 <br /> Application Accepted-__byr �/�,Gzn�/ . Area --'� _ <br /> �;i � Lodi 364-3621 <br /> Additional Comments: { Manteca 823-7104 <br /> Pit or Grout lnspectio;n by Date <br /> Date ?-- <br /> Final Inspection by <br /> 5 Tracy 835-6385 <br /> — '3 L <br /> dealt Permit/Seryice� 160 E. Hazelt A P. ox 2009, Stk., CA 95201 <br /> Applicant - Return all i it mental <br /> FEE BASE AMO T DUE AMOUNT REMITTED RECEIVED BY <br /> D TE PERMIT N0. <br /> INFO �3�Ib <br /> ' .o �O• oa <br /> 10/82 500 <br /> EH 13-24 REV. 10182 <br /> 14-26 <br />