Laserfiche WebLink
Q <br /> APPLICATION FOR'PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> tKI 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 PAVA4LrN7. <br /> PERMIT EXPIRES I'YEAR FROM DATE ISSUEDRec'e, <br /> (Complete in Triplicate) <br /> t. --is hereby made-to-the-Sa n Joaquin-Local Health.District.!or,a pe",iy tp,construct and/or.install tmvk A&W abed. This application is <br /> 'pu, "he R I e lons of-, hd"San Joaquin <br /> pp rea ion <br /> made in compliance��'itK.'San--Jo'aqLii'h'Cou'n'ty'()rdinanr-e''Na,549 f6r sewage or-No'.,1862 for.weli/ u as an 't t <br /> al H ii <br /> -tp <br /> QNM <br /> Loc Health D <br /> PERA�l <br /> Job Address AVE city EXr&,214_J_ Lot Size/RJ_C!W5, PM,, <br /> Owner's Name Foej4&K 1PdqEA1 F-2 Address q76100 <br /> 4f — <br /> Contractor DaWA6,,!rdre,,3_0_0 s- --- . ense N,7212&Z--Phan_Q <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT DESTRUCTION 1-1 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C1 OTHER 17 <br /> DISTANCE,TO NEAREST:,SEPTIC TANK SEWER LINES DISPOSAL FLO.L7AQe/�PROP. LINE <br /> FOUNDATION PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial C1 Open-Bottom ti L•Manteca _Di a--,of Well Excavation Dia. of Well Casing <br /> ,x-Domestic/Private '21�0ravel Pack" E] Tracy ITXpe of Casing—)21K to a/ Specifications <br /> n Public F1 Other n Delta Depth of Grout Seal 15 217;1, Type of Grout,551MVM57 <br /> I i Irrigation X7A6__App(ox. Depth pastern Surface Seal Installed by <br /> Repair Work Done D Type of Pump State Work Done <br /> Well Destruction El Well Diameter Sealing Material atop 50j) <br /> Depth Filler Material (Below 41 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I'll REPAIR IADDITION (.1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercia,11— Other <br /> Number of living units. Number of badroomp' s I <br /> Character of soil to a depth of 3 feel- Water table depth <br /> SEPTIC TANK 0 Type/Mfgcity_ No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property1ine <br /> LEACHING LINE F1 No. & Le'ngth of lines Total length/size <br /> FILTER BED L1 Distance to nearest: Well Foundation— Property Line <br /> SEEPAGE PITS I I. �oplh Size Number <br /> ., SUMPS I-] 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 Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di%trict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the,performance of the work for which this permit is issued, 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 the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California. <br /> The applia mu c for#I/equired inspections. Complete drawing oAmers�esi <br /> Signed Titl Z&K —?a_x4PZk.I-_ Date: <br /> FOR DEPARTMENT US' NLYj <br /> Application Accepted by Date Area <br /> Pit ovGro9f Inspection by Date — Final Inspection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 0 Lodi 369-3621 EI Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I, <br /> FEE AMOUNT DUE AMOUNT REmmrED CK,1 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> 4--� 4. Jr <br /> EH 11 3-24 IR 1. -7 6,�� _Z <br /> EH 4-28 EV.i/mw ' 62 213 Fit: <br />