Laserfiche WebLink
APPLICATION FOR PERMIT ' <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 16D1 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �3 ` <br /> Telephone (209) 466-6781 <br /> DATE ISSUED s 1 <br /> PERMIT EXPIRES-I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) " <br /> Application is hereby made to the San Joaquin Local Health District Ar a permit to construct and/or install the work herein, <br /> r 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'San Joaquin Local Health District, <br /> Job Address 86W 3.i=8-Rd: Subdivision Name <br /> Owner's Name fl Address Phone <br /> Contractor's Name 1. License No. a Phone <br /> OL� <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES )p DISPOSAL FLD. PROP. LINE rr1 <br /> FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS W s <br /> INTENDED USE TYPE OF -WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <br /> I] Industrial []open Bottom ❑ Manteca Dia, of Well Excavation <br /> Domestic/Private 0 Gravel Pack Tracy Dia, of Well Casing <br /> Publ is Other ' ]Delta ` <br /> Type of Casing <br /> Lj Irrigation Approx. 0 Eastern Specifications <br /> F-ICathodic Protection Depth rid. <br /> EJ Geophysical <br /> Depth of Grout Seal <br /> ' <br /> Other Type of Grout <br /> Surface 5eal.Installed by f <br /> Repair Work Done Type of Pump Sll H.P. �2 i- State Work Done mplaced, pump ) <br /> Well Destruction U Well Diameter 71 ' Sealing Material (top 50'} <br /> i <br /> Depth L Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION LI (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) 6 <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units- <br /> Number of bedrooms M Lot size <br /> Character of soil to a depth of 3 feet: Water table depth f <br /> SEPTIC TANK Cj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, {] Type/Mfg "1 Capacity Method, of Disposal <br /> Distance to nearest: fell """`Foundation Property Line <br /> LEACHING LINE U 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-- U Dpistance to nearest: Well Foundation - --Property Line* - � <br /> 1 <br /> DISPOSAL PONDS ED <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,Loca]_Health District. <br /> Hom0owner 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 /> 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 applicant st call or all required i pections. Complete drawing on re a side. <br /> Signed X Title: Date: <br /> � 1---- `-//, <br /> F�y EP TMENT USE ONLY �[ <br /> Application Accepted by Area T� 7- 9 -3 [] Stk 466-6781 <br /> Additional Comments: �] Lodi 369-362.1 <br /> Pit or Grout Inspection by Date" [ Manteca 823-7104 <br /> Final Inspection by 9 c �Date -,�F 7-01 3 Tracy 835-6385 , <br /> Applicant - Return all copies to: Enviro ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE yFBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> s -93 <br /> :3 <br /> 13-24 REV. 10/82 10/82 500 <br /> 14-26 i <br />