Laserfiche WebLink
APPLICATIOAIFP <br /> R PERMIT <br /> SAN JOA(I1JIAI=LQCA>+. HEALTH DISTRIQT <br /> 1601 E. HAZEL T ON AVE., STOCKTON,Ti <br /> Telephone (209) 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•forvoell/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District; <br /> 04-1 <br /> Job Address (J / Cir * <br /> _ Lot Size ` �---- -�— <br /> Owner's Name l Address Phone <br /> / �/� Q <br /> Cootractgr f ddfess �/W/r Lice Na. � Phonate ':32/0 <br /> TYPE OF WELL>$UT qP^ �, WE L't� WELL REPLACEMENT ❑ DESTRUCTION C 1Al` <br /> ' PUMP INSTALLATION ❑ ` SYSTEIVI RE'P7k W,Q OTHER ❑ <br /> DtSTA ,f TO kjAko: '3EPTIG Tft SMER L`NEti"=; _ DISPOSAL FLD. PROP. LINE <br /> FOU NDA ION _. AGti1CULT1JRtWELL OTHER SHELL PITS/SUMPS _ <br /> INTENDED USE . , TYPE OF WELL PROBLEM AREA, rAG STRUCTION,SPECIFICATIONS <br /> ❑Industrial ❑ Open&ttbm " °-` 7 Mlrnteea %Dile'. of Well Excavation Dia. of Welt Casing <br /> ❑-6eawstic/RrivW4 ❑'Gnsltril Peck ❑ TTscy `' Type of Casing Specifications <br /> n Public n, Other. n Delta p h Qf Grout Seal Type of Grout <br /> I I Irrigation ^_ `. ,./CAprltit. Dept ft t_- tern aurface Seal Installed by <br /> Repair W1>fk Ooh "O Type`oi , H.p. :itifdfflfo falPrre` l 11 <br /> Well Delttruction Sealing Material(top 501 1046for /A r el e ALe <br /> Dept Filler Material (Bebw b0'I AM <br /> TYPE OE,WTIC WORK: NEW INSTALLATION I l 'REPAIR/ADDITION i 1 DESTRUCTION I 1 INo septic system permitted if public sswvO is <br /> availab►e=vvithire 200 feet.)` <br /> -;Jns,tq#ation will serve: Reskience ';%nmercial_,_„ Other i� <br /> Number,of,living units:. Number of bedrooms `* "(�l <br /> Character df soil to a depth of 3 feet: Water table depth \ <br /> SEPT1C TANK.- ❑ Type/Mfg Capacttlr "' No. Compannvrits <br /> PKG. TREATMENT PLT.❑ Method of Disposal: <br /> p ' Distance-to neat: We4 :- Foundation Property Line <br /> LE/;cCHING LINE ❑ No. &Length of livres Total length/size <br /> FILTER BEI) ❑ Distance to.nearest: won Foundation Property Line <br /> f <br /> SEEPAGE PITS I I Depth Size Number <br /> `SUMPS , 0 Distance to nearest.. Well ' Foundation Property Line <br /> .01APOSA PONDS ❑ <br /> I hereby certify that I haver-prepared.this.applieatiert-,,and-that the work will be done in accordance with San Joaquin county ordinances, state lawns, and <br /> ruletand 4gulations of the San JoaquinLocal Health Dibtrict. <br /> Honig owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is isaied,i shall not ` <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t6 following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's conVensa <br /> tion lava of-California." <br /> _... .___ <br /> The applicant all ed inspectiatns. Complete drawing on side. <br /> Title: _ L_ Date '' +�d <br /> PA tyENTAE ONLY <br /> Application Accepted by CAM ,;al .T*Skma CA m `�1,r Date �"Z_"� �0 Ansa <br /> Pit or Grout Inspection by Date Final inspection by &t1 Aftd) <br /> Dom!-�.-, � <br /> Additional Comments: Nl <br /> ❑ Stk 4664781 0Lodi 388.3621 ❑ Manteca 823.7104 ❑ Tracy <br /> Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008; Stk., CA 0=1FEE <br /> .. <br /> INFO AMOUNT OUE AMOUNT IIEMI CASH RECEIVED BY DATE PERMIT'NO.EN M24 t Y <br /> + EH 11-16(REV.1i85l n� ��i Db 3 <br />