Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. — 7 7 , r <br /> Telephone (209) 466-6781 DATE ISSUED 7 <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 Joaquin Local Health District. �-g- <br /> Job Address_ �� �Z_ f pi[ _ C1— __ Subdivision Name <br /> Owner's Name1' ' �frciln t3 _ Address 3o, f fax ' .� Phone -- <br /> Contractor's Name License No. Phone <br /> 1 I , <br /> TYPE OF WELL/PUMP WORK: NEL! WELL � WELL REPLACEMENT r7 DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER L a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLD. PROP. LINE (.Q <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SJMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l� <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation Q <br /> Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public -J Other Delta Type of Casing Aff C_ �+ I <br /> Irrigation 1,eL0 Approx. Eastern <br /> Depth Specifications e�9� �'"r�__ 1•� 'i <br /> F—ICathodic Protection Depth of Grout Seal <br /> 1-1 Geophysical /�{ /�/ Q <br /> C r`��� � ✓ G Type of Grout C <br /> Other W" y �fyy <br /> Surface Seal Installed b � <br /> Repair Work Done L] Type of Pump H.P. State Work Done "i <br /> .Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE Of SEPTIC,WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (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: Number, of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth r <br /> SEPTIC TANK Type/Mfg ° Capacity No. Compartments {� <br /> PKG. TREATMENT PLT. [! Type/Mfg Capacity Method of Disposal T1 <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE [ No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS [ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS [I <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 employ any person in such manner as to become subject to workman compensation laws of California." <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 /> The applican call or 11 equired inspections. Complete dratiing on reverse side. <br /> Signed X <br /> Title: Date: <br /> FO A <br /> Application.Accepted _ rea Stk 466-6781 <br /> Additional Comment : 74 -% — [� Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date �3 f7' Tracy 835-6385 <br /> Applicant - Return all copies to;. Enviro tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT NO. <br /> INFO <br /> -7 J $3- <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />