Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQLi"; LOCAL HEALTH OiSTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 �� <br /> DATE ISSUEp <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hers y 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 agd gu at' n of the a Joaquin}}hbca h Di <br /> Healts tct. <br /> Job Address ( '1l � �'{ �GZ, t cion Name <br /> Owner's Name ` e Z ,/' 33Address �/!7 !'�tr Phone <br /> Contractor's Name f �� License No. Phone yy <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTIONS❑ �G] <br /> ,n PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER r j <br /> Yy } DISTANCE TO NEAREST: C TANK SEWER LINES. DISPO PROP. LINE 1 <br /> o!✓� FOUNDAT AGRICULTURE WELL ER WELL f PITS/SUMPS <br /> INTENDED USE TYPE OF PROBLEM AREA 'TRUCTION SPECIFICATIONS <br /> VVV"' ❑ Industrial ❑Open Bottom Manteca Dia, of Well Excavation <br /> N0 Domestic/Private tel) <br /> Gravel Pack ❑ Dia, of Well Casing <br /> Fe;^ — Public Other elta $�4 Type of Casing V Irrigation Appro Q Eastern <br /> D 'fications G©G,_ <br /> ❑ Cathodic Protection� Depth of Seal� [-IGeophysical <br /> UOther <br /> Type of Grout U n t• <br /> Surface Seal Installed by !7 L'(.► <br /> Repair Work Done Type of Pump �� tM H.P. l 5 State Work Done <br /> Well Destruction U Well Diameter $' Sealing Material (top 50') Crv�[ / _ 141' <br /> Depth �S -7,0, Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONS REPAIR/ADDITION J1 (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) Ov� <br /> Installation will serve: R 'dente _ Commercial Other C>6Number of living units: Number of bedrooms �� Lot size 1S / <br /> Character of soil to a depth of 3 feet: Water table depth �V <br /> SEPTIC TANK Type/Mfg Co 11 C Capacity 00 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal, , .5 <br /> SEWAGE SYSTEM Distance to nearest: Well ` D _ Foundation Property Line <br /> /!?Off <br /> DESTRUCTION <br /> LEACHING LINE No, & Length of lines •L.5 10 D A tal length/size - 3 3 i-� <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth `� Size Number - <br /> / <br /> �� <br /> SUMPS ❑ Distance to nearest: Well 10 if Foundation /3 d Property Line tr� <br /> DISPOSAL PONDS ❑ <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 sued, I shall not employ any person in such manner as to become subject to workman'§ compensation laws of California." <br /> Contr is 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 /> Th[F applica us call for all � it re spections. Complete drawing on reverse side. <br /> �(J Date: •-�O -v�� <br /> Signed X � .-�_ .tc� Title: ( �L- <br /> F PART 4AT USE ONLY <br /> Application Accepted by Area � -S t k 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> G�Por Grout Inspection by Date 3 ❑ Manteca 823-7104 <br /> y Final Inspection by Date _ ❑ Tracy 835-6385 <br /> Applicant - Return all copies t nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> -445 1 IX 93- <br /> EH 13-24 REV. 10/82 ^� 10/82 500 <br /> 14-26 1 <br />