Laserfiche WebLink
f N <br /> r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. FAZELTON AVE., STOCKTON, CA PERMIT NO. $�r-!Q"6_5 <br /> Telephone (209) 466-6781 <br /> DATE ISSUED oZl3 <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 S--an Join L cal Health District. <br /> Job AddressSubdivision Name <br /> i <br /> Owner's Name 1 �� Address0_11Z4_9 =:Vs Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: ' NEW WELL. ❑ WELL REPLACEMENT DESTRUCTION W <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE C <br /> O <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Cf <br /> INTENDED USE TYPE OF WELL PR03LEM AREA CONSTRUCTION SPECIFICATIONS l/ 41 <br /> !J Industrial U Open Bottom F_� Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack [f Tracy Dia. of Well Casing <br /> Public Other Delta Type of Casing ! <br /> V Irrigation Approx. Eastern Specifications <br /> F-ICathodic Protection Depth Depth of Grout seal <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> Repair Work Done [—] Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW TNSTALLATION ; _ REPAI N (No septic tank or seepage pit permitted if public sewer is ) <br /> available within 200 feet.) <br /> Installation will serve: Residence }� Commercial _ Other 11 <br /> Number of living units: Number of bedrooms 0? — Lot size I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> i tY J�DD�3Y�� p <br /> SEPTIC TANK � Type/Mfg No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM t4stance-to nearest: Well F44�rid tion Property Line <br /> DESTRUCTION ,f a yA� / <br /> LEACHING LINE No. & Length of lines Total length/size (¢ <br /> FILTER BED Distance to nearest: Well Foundation Property Line G <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <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 became subject to workman Is 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 perso s subject to workman's compensation laws of California." <br /> The applicant st c 1 for a q spec tions. Complete drawing on reverse side. n <br /> Signed X Title: P Date: <br /> R RTMENT USE ONLY <br /> Xp <br /> ication Accepted b r0.r Area Stk <br /> 466-6781 <br /> tional Comments: [J Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by . bate L Tracy 835-6385 <br /> Applicant - Return all copies Environmental Health Perm' er es 1 H el to Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NQ, <br /> INFO n , ?DISS <br /> EH 13-24 REV. 10/82 /� d 10/82 500 <br />