Laserfiche WebLink
y <br /> 1 <br /> APPLICRTION FOR PERMIT s <br /> SAN JOAQUIN LOCAL HE41`H DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> k. (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cC. 5 <br /> ,r inta 1 work herein <br /> described. This application is made in Compliance with San Joaquin County Ordinance fo`r se a,g No. 862 for well/pump <br /> and the Rulesn(I Re ululj+attions c the San Joaquin Local health District. <br /> Job Address r�� ! / MA N'k�<A R OAOubdivision Name 1J <br /> Owner's Name C14A RW a/2" .+ H4 Address Phone <br /> Contractor's Name 2 C bice License No. `)/ Phone $%6'(,� � <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP 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 SPECI-FICATIONS <br /> I industrial U Open Bottom [] Manteca Dia. of Well Excavation <br /> LJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public �J Other 0 Delta <br /> irri anon Type of Casing <br /> L_i . 9 Approx. Eastern <br /> Specifications <br /> ❑ Depth <br /> Cathodic Protection p pepth of Grout Seal <br /> 17 Geophysical <br /> LJ Other Type of Grout <br /> 4 Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well. Destruction U Well Diameter Sealing Material (tap 501) <br /> # Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) S� <br /> Installation will serve: Residence X Commercial _ Other ` <br /> Number of living units; __-_� Number of bedrooms _� Lot size — 7 Acw-& <br /> Character of soil to a depth of 3 feet: <br /> 5 P : _1kV© 'Water table depth <br /> SEPTIC TANK U Type/Mfg Capacity No. Compartments �. <br /> PKG'. TREATMENT PLT, Type/Mfg Capacity Method of Disposal ^ <br /> SEWAGE SYSTEMDistance 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 /> SEEPAGE PITS .' Depth Size Number <br /> SUMPS p U Distance to nearest: Well. .Foundation Property Line <br /> DISPOSAL PONDS <br /> 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 /> ord'inances,;state laws, and rules and regulations of the San Joaquin Local Health District. 1 <br /> Home owner or licensed agent's signature certifies the following_ "I certify, that inthe perfprmance­of tiG work for which this Li <br /> permit is issued, I shall not employ any person.in such manner as to become subject to workman's 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 ap.plicant,.yst call for all requi ed inspections. Complete drawing on reverse side. <br /> Signed X (fy►-� Title: L`C, V4%- - Date:. -1,9' L <br /> FOR OE ARTMENT USE ONLY' <br /> Application Accepted by 5-�\- IJI Z14Area �� [� .Stk 466-6781 _ ` <br /> Additional Comments: _ Lodi 369-3621 <br /> Pit or Grout Inspection by, Date It<-Manteca 823-7104 <br /> �Final Inspection by <br /> _ Tracy $35-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazel on Ave„ P.O. Box 2004, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> ^EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />