Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL Hi ALTH DISTRICT <br /> PERMIT N0. 63- <br /> 1601 <br /> 3+1601 E <br /> Telephone N(204) 466-6781N' .CA <br /> DATE ISSUED �n`1�"g3 <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 /> 1 , <br /> described. This application is made in compliance with San Joaquin,County Ordinance No. 549 for sewage or No. 1862 for we pump A <br /> and the Rules and Regulations.of the San Joaquin Local Health District, <br /> Subdivision Nam <br /> Job Address Address Phone <br /> Owner's Name , Phone i&_ � <br /> License No. <br /> Contractor's Name <br /> I NEW WELL DESTRUCTION CSS <br /> WELL REPLACEMENT Q ❑ _ I <br /> TYPE OF WELL/PUMP WORK: uOTHER <br /> PUMP INSTALLATION SYSTEM REPAIR -­7 <br /> SEWER LINES _ `�DISPOSAL�FLO -ti PROP. LINE <br /> D[STANCETO"NEAREST: 5EPT1C TANK PITS/SUMPS <br /> r FOUNDATION AGRICULTURE WELL+.... - -;-_�- OTHER WELL <br /> ti ' <br /> INTENDED=USE TYPE OF WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIDNS 1 <br /> �J <br /> U Open Bottom [� Mant6ca Dia. of Well Excavation s <br /> Trac: Dia. of <br /> industrial Well Casing <br /> ❑ Domestic/Private] �] Gravel Pack ❑ Y <br /> Public <br /> []Other Delta. Type of Casing <br /> , 'F <br /> Approx. Eastern 5pecificafions <br /> Li Irrigation ❑ <br /> Cathodic Protection'', i. <br /> Depth Depth of Grout Seal <br /> 01 <br /> Geophysical V Type of e Sea , Dq <br /> Surface Seal <br /> Installed by <br /> ❑Other f <br /> T e Pum <br /> K.P. '? State Work Done <br /> Repair Work Done ❑ Yp p � . ._ <br /> Well Destruction ❑ Well Diameter <br /> Sealing'Material (top 50') <br /> Depth Filler Material (Below 50') <br /> °R <br /> ! available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTRLLATI REPAIR/.ADDITION (No septic tank or seepage pit permitted IJ if public sewer is <br /> installation will serve: Residence Commercial Other f <br /> Number of bedrooms Lot size <br /> Number of living units: � c Water table depth <br /> Character of,rsoil_rto a dep h of 3 fe _ k Np, Compartments <br /> `3_ i Mf gaci'ty .s <br /> SEPTIC TANK ,*-T yp e/ 9- Ca acit Met od of Disposal ' <br /> $ P f.y� --� <br /> PKG. TREATMENT PLT. ❑t Type%Mfg Foundation. Property Line <br /> SEWAGE SYSTEM t „Distance to nearest: Well <br /> DESTRUCTION ❑ T + -� <br /> 4 ` a Total length/size <br /> { LEACHING Li NE 'No.� &�q,L•ength of lines Property Line <br /> -,-_ 0 A: Foundations P <br /> FILTER BED Distance to nearest: Well <br /> k r sI <br /> Size AYNumber <br /> SEEP.AGEPITS;r{r r De pth. - 4/""'Property Line <br /> *^" <br /> SUMPS" "�""� �� Distance to,nearest: Well Foundation,�_ <br /> OISP05AL PONDS ❑ ~ _ <br /> I[ I hereby certify that I have prepared--Lhi-s-application and that the,w4rk will be done in accordance with San Joaquin county <br /> performance of the work for which this <br /> ordinances, state laws, and rules and regulationsk.of the"5an4Joaqu n�4{ocal ,Healththat in the <br /> Home owner or licensed agent's signature certifies the following: I Certify subject that in the p <br /> permit is issued, I shall nocontemp]ractynan person inertifiesmanner <br /> the following:m" certifytthatrinathecperrformancce ofwthefwork�for nwhich <br /> Contractor's 9 or <br /> su to workman's compensation laws of California." <br /> this permit i sued, I shall employ persons � <br /> for ir spe io s. Comp to g on reverse side. <br /> lica <br /> The app _-requpate: <br /> Title: <br /> Signed X <br /> R DEP TM ENT USE ONLY Stk <br /> Area �� 466-5781 <br /> pplication Accepted by , � v f� Lodi 369-3621 <br /> f rn <br /> f Additional Comments: r Date ti "� I� Manteca 823-7104 <br /> Pit or Grout Inspection.by pate /d-/7 Tracy 835-6385 <br /> Final Inspection by-., <br /> Applicant - Return all copies to: . Environmental Health Permit/.Ser_vicesf1601_�E.;Hazelton e., P.O. Box 2009, Stk., CA 95201 <br /> F pp f <br /> - .=�... DATE PERMIT N0. <br /> -,.•---- — -'°RECEIVED BY--- <br /> FEE �BASE AMOUNTDUE <br /> 1N F0 pp`" j�a-11s�z3 t$3-114i <br /> --10/82 500 - «. <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />