Laserfiche WebLink
APPLICATION FOR;PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT $3— I oZ-ir t <br /> ZS <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 43 — <br /> Telephone (209) 466-6781 DATE ISSUED Cl—)lo`IR <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 the San Joaquin Lo 1 ealth District. <br /> Job Address_/Z— ' rle Y Subdivision Name.. <br /> ' r Address Phone <br /> Owner's Name <br /> Phone <br /> Contractor's Name Nr License No <br /> TYPE OF WELL/PUMP WORK: _ NEW WELL REPLACEMENT DESTRUCTION �) C <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK`S SEWER LINES 1,0 _ DISPOSAL FLO.' PROP, LINE <br /> {4 FOUNDATION i f/ AGRICULTURE WELL OTHER WELL 100�4- PITS/SUMPS <br /> INTENDED USE TYPEIOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �2/KL�I <br /> ❑ Industrial ❑ope' Bottom Manteca Dia, of Well Excavation <br /> zi- <br /> ffe ime Private ra1v1el Pack Tracy 01a. of Well Casing /�rPG <br /> ❑ Public D othAr Delta Type of Casing A� <br /> O.Irrigation 4Approx. Eastern Specifications <br /> Cathodic Protection Depth Depth of Grout Seal ys <br /> r ❑Geophysical Type of Grout re <br /> ❑Other1 Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pum p''s�4 k1p. '3 State Work Done <br /> i <br /> I <br /> Well Destruction D Well Diameter Sealing Material (tap 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEN INSTALLATION �J REPAIR/ADDITION U (No septic tank or seepage pi avat ableewithinu200c feet.) is <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; <br /> Water table depth <br /> SEPTIC TANK %Type/Mfg ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/M!, <br /> Capacity Method of Disposal <br /> SEWAGE SYSTEM oDi'tanle to nearest: Well Foundation Property Line <br /> DESTRUCTION i ' <br /> LEACHING LINE U No.,A Length of lines Total length/size <br /> FILTER BED n DistanlCe to nearest: Well Foundation Property Line <br /> SEEPAGE PITS M Depth I Size Number <br /> Distance Co nearest: Well Foundation Property Line <br /> SUMPS U <br /> DISPOSAL PONDS CI <br /> I1 <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 far which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I:cerlaws 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 appli ant mu all fora i ed inspections. Complete drawing on reverse side. Date: <br /> Sig <br /> DEPARTMEo 3 Stk 466-6781 <br /> Appllcati cteptec bY' Area <br /> Lodi 369-3621 . <br /> Additional Comments' Date 3 ❑ Manteca 823-7104 <br /> Pit o G ou Ins n Date �j—1 .,� EJ Tracy 835-6385 <br /> Final Inspection by' <br /> es t': Environmental Health Permit Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., LA 95201 <br /> Applicant - Return all copi <br /> .RECEIVED BY, DATE PERMIT NO. <br /> r FEE -BASE. AM069T. .DUE. .AMOUNT REMITTED . _lG ��� <br /> I INFO � },] —�(o'e) _ .tNIQ <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br />