Laserfiche WebLink
A� t <br /> APPLICATION FOR PE!R it T <br /> SAN JOAQLiN LOCA: HEALTH -D STRICT —��� <br /> 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 'g3 <br /> Telephone (209) 466-6781 DATE ISSUED <br /> . <br /> / PERMIT EXPIRES 1 YEAR FROM GATE 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 /> desctibed. 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 L Subdivision Name I <br /> Owne'r's NameAddress .!P Q , sy? <br /> Contractor's Name G�,u„r�:-�/ ri�l ra License No. 5�74 i Phone , a� <br /> • "_' W {JJ <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK /S'y� 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 'V <br /> Domestic/Private Gravel Pack Tracy Dia. of Well Casing f !, <br /> Public Cl Other E] Delta Type of Casing <br /> Li Irrigation _10,6 • Approx. Eastern Specifications c-- <br /> Cathodic ProtectionDepth <br /> F-11CthdiF <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> Other Surface Seal Installed by ��,� /►[res ��` <br /> Repair Work Done E] Type of Pump � H.P. State Work Done <br /> Well Destruction Lf Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION E (No septic tank or seepage pit permitted if public sewer is r <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments l <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 U No. & Length of line-s 1 Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> T - <br /> SEEPAGE PITS ❑ 'Depth / Size ' Number <br /> SUMPS U 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 become subject to workman compensation laws of California." <br /> --c6htractor''s`h-ring'or sub-'contracting signature certifies"the following: "I certify that'"iii+th-e performance"of-the--work-for-wirier- � <br /> this permit is issued, I shall employ persons subject to workman's compensationlaws of California." <br /> y : <br /> The applicant mu cali ections. Complete drawing on reyerse ide. <br /> Signed X Tit s - Date: <br /> `I OR DEPARTMENT USE ONLY <br /> Applicatio cepted by Area J J [�]/Stk 466-6781 <br /> Additional Comments: a 'r •%!� lnw�� i�.�� r k . L Lodi 369-3621 <br /> Pit or Grout Inspection by D . e P J Manteca 823-7104 <br /> Final Inspection by r <br /> Tracy 835-6385 <br /> Applicant - Return all co piles to�En onmenta Health Prmt/Services 1601 E7 VS, P.0 ox 2009, St k., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVE�BY �DAT�l �PER�miTIN101.,INFOac7 <br /> 0C <br /> r EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />