Laserfiche WebLink
} <br /> APPLICATION FOR 'PERMIT • <br /> ' SAN ,JOAQUIN LOCAL HEALTH DISTRICT <br /> HAZONAVE11E. E % , STOCCTON, CA <br /> " <br /> -�- Telephone 1209? 466-6781 <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 described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. LLJ <br /> Job Address _� �- <br /> _ Cit t Size PM <br /> Owner's me Fei <br /> I^ab b[ �f s'rn'w`y phone -fou-_6 v 3� <br /> t Address License-No/ Z 7 Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑l WELL REPLACEMENT L-1 DES TRUCTION L1PUMP INSTALLATION lid I SYSTEM REPAIR ❑ OTHER ❑ <br /> I — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE:OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom fl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 6mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f] Public ( Other n Delta Depth of Grout Seal Type of Grout <br /> I ] Irrigation �`� —..Approx. Depth { I Eastern Surface Seal Installed by <br /> Repaii,Work Done L+�' -Type of Pump ._ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE SOF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> r available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other W <br /> Number of living units: Number of bedrooms <br /> v Character of soil.to a depth of 3 feet: Water table depth <br /> SEPTIC TANK rte.,bti ❑ <br /> IM g3- Capacity - No. Compartments <br /> i l J 1 Method of Disposal <br /> PKG.'TREATMENT PLT.'❑ - <br />'i g <br /> i # Distance to nearest: Welf Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines w Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property.Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that,the work will be done'in accordance-with�San:loagisin county ordinances, 11aws, <br /> rules and regulations of oaquin Local Health District"^�-�-----.�..,.,.a.,...--,.:--� T - "Y� -1111_ ""��" <br /> Home owner ar lice d agent's sig tore certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any pars in such manner as to become sub t to wor n's compensation.laws-of_CaGfornia." Contractor's hiring or sub contracting signature <br /> certifies the fot wing: "I certify that i t Performa th o for wh- his pe it is issued, I shall employ'persdns subject to workman's compensa- <br /> ik` tion laws of alifornia." ' r <br /> y <br /> The applica must call or all u- dins c' w g on r s +de. <br /> t <br /> /Q - -�' <br /> Signed X le: ate: <br /> s <br /> FO PARTMENT USE ONLY <br /> bate <br /> s Application Accepted by IrJ� T ti Area <br /> t Finalitns action*b Date <br /> Pit or•Grout-Inspection by ----Date p Y O <br /> Z_4 2. <br /> Additional Comments: <br /> " ❑ Stk 46&6781,__.Q Lodi--369x3621— 'D-Manteca-"823-7104 835=6385--� <br /> � Appliclant- Return all copies to: Envirorimentat Health.Permit/Services 11601 E.`Hezeltion.Ave., P.O. Box 2009, Stk., CA 45201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> RECEIVED BY DATE PERMIT NO. <br /> INFO L <br /> + EH 13-24 IREV.1 r R 51 11 I` 0 <br /> CH 14-28 <br /> 14-28 <br />