Laserfiche WebLink
APPLICATION F0 PEK T <br /> SAN SOAQLiN LOCAL HEP%LTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> F1 GATE ISSUED _\D <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Tripl.11) <br /> Fi Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> b 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. <br /> Job Address/�I <br /> Subdivision Name <br /> i Owner's Name Address lal,41 Phone- <br /> { Contractor's Name License No. _3901122-4--, Phone <br /> F! TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> ' POMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom []Manteca Dia. of Well Excavation <br /> IJ Domestic/Private FJ Gravel Pack ❑Tracy Dia. of Well Casing <br /> F Public LJ Other Delta Type of Casing <br /> LjIrrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> i <br /> h <br /> — Depth of Grout Seal <br /> Geophysical Type of Grout <br /> t_JOther Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done Q <br /> riWell Destruction L} Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [J REPAIR/ADDITION J (No septic tank or seepage.pit permitted if public sewer is <br /> F available within 200 feet.) ?� <br /> Installation will serve: Residence Commercial � Other <br /> I — t+ <br /> Number of living units: Number of bedrooms Lot size ✓QCiLls1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> F SEPTIC TANK �! Type/Mfg it r,.i G/y o Capacity /�n4 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line � - <br /> DESTRUCTION — <br /> LEACHING LINE LJ No. & Length of lines Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth size Gs Number 3 <br /> k <br /> SUMPS Lj Distance to nearest: Well l�4�Foundation � Property Line <br /> DISPOSAL PONDS CI <br /> I hereby certify that I have prepared this application and that the work -will bg 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, 1 shall not employ any Person in such manner as to become subject to piorkmant 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 comperisation laws of California." <br /> The applicant �tll �fo/r�all aired inspections, Complete drawing on reverse side. <br /> Signed 7f Wil_ y � - _ Title: Date: Z � y <br /> t F DEPARTMENTUSE dLY ❑ <br /> Application Accepted by Area ,L Stk 466-676I <br /> Additional Comments: Lodi 369-3621 <br /> i or Graut Inspection by' Date - D Manteca 823-7104 <br /> Final Inspection by Date --�Lf 0 Tracy 835-6385 <br /> Applicant - Return all copies to: . Environmental ealth Permit/Services 1601 E. Hazelton AvC., P.O. Box 2409, Stk., CA 95201 <br /> FFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED B�Yt DATE PERMIT N0. <br /> INFO <br /> T--I <br /> EH 13-24 REV. 10/82 10/82 540 <br /> 14-26 <br />