Laserfiche WebLink
r <br /> i <br /> to APPLICATION FOR PERMIT <br /> SAN JOAO,UIN LOCAL CE ESTOCKTON ALTH GA <br /> DISTRICT <br /> 1601 E. HAZE I O 6781 <br /> Telephone (249) 466- <br /> PERMiT EXPIRES 1 YEAR FROM DATE ISSUED w <br /> (Complete in"Triplicate) application's y <br /> ulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Health District for a p <br /> erm;t to construct and/or install <br /> the Rules and rR described.This app r <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump PM <br /> Local Health District. ( Lot Size <br /> city �. <br /> Job Address Phone <br /> rJ� Addressc C)" <br /> Owner's Name 1X r �Z 4' Phone <br /> t License NO- <br /> G AddressPei DESTR <br /> UCTION ❑ <br /> Contract NEW WELL ❑ WELL REPLACEMENT ElOTHER ❑ <br /> TYPE OF WELLIPUMP: . SYSTEM REPAIR Ell PROP,PROP. LINE <br /> PUMP INSTALLATION ❑ DISPOSAL <br /> SEWER LiNES � QTHEfl W PlTSI5UMPS �- a <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL <br /> FOUNDATION 1 CONSTRUCTION IFICATlONS I , <br /> TYPE OF WELL <br /> PROBLEM Dia. of WeV1 Casing <br /> INTENDED USE Dia. of xcavation <br /> ❑ Open Bottom ❑ Manteca Specifications <br /> ❑ Industrial k ❑ Tracy T of Casing Type of Grout <br /> LDDomestic/Private ❑ Gravel PacDepth of Grout Seal <br /> Other ❑ Delta <br /> r-1 Public C3 other <br /> Surface Seal installed by <br /> ---Approx. Depth State Work Done <br /> [I irrigation H.P. <br /> Repair Work Done ❑ Type of Pump <br /> Seating Material atop 501 <br /> Well Destruction L7 Weil Diameter <br /> se <br /> Depth Filler Material (Below 50') permitted ;f public sewer is <br /> REPAIRIADDITION Cl DESTRUC710N ❑ aNailablerwithin e200 feet.l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ / <br /> Commercial� Other <br /> installation will serve: Residence— Water table depth <br /> Number of bedrooms <br /> Number of living units: No- Compartments <br /> Character of soil to a depth of 3 feet: Capacity` <br /> SEPTIC TANK ❑ Type/Mfg J Method of Disposal <br /> Property Line <br /> PKG. TREATMENT PLT. F1 Foundation <br /> Foundation f <br /> I Distance to nares _Well� IF <br /> � <br /> _ Total lengthlsize_� X! " <br /> [�No. a Length of lines <br /> LEACHING LINE FoundationProperty Line FILTER BED F] Distance to nearest: Well_ �— <br /> ` it _ <br /> -�N"rn e <br /> ❑ Depth S� '-Siie-' <br /> SEEPAGE PITS j 6 Foundation�� Property Line <br /> SUMPS Distance to nearest: Wet1 , <br /> DISPOSAL PONDS ❑ <br /> V have prepared this application and that the work will.,be done in accordance with San Joaquin county ordinances, state laws, and . <br /> { hereby certify thaty"t"""1 t <br /> rules and regulations of thes•,gnaturre cocalertifies tFie folbrwing"I certify that in the performance of the work for which this permit is issued, l shall not <br /> Home owner or licensed agent'sns subject to workman's compensa- <br /> ce of the work for which this-permitis issued,.1.shall employ PI <br /> em to any person in such manner as to become subject to workman's compensation laws of Galifornia.' Contractor s hiring or sub-contracting signature <br /> P Y -- <br /> certifies the following: "I certify that in the performs �_ — � <br /> tion laws of California." <br /> The applicant ust call for required inspections. Complete drawing on!�eder� T/J Date: L <br /> + ' Title:- '' <br /> Signed X L <br /> _r FOR:DEPARTMENT USE-ONLY <br /> Area <br /> Application Accepted by �• <br /> ate . <br /> PP .A _s "� � " Fina{ inspection by <br /> Date - <br /> P" r GrRIMIments:-�-'­ <br /> inspection by <br /> A ditio �" ❑ Manteca" g ,710a k-•f ❑-Tracy, 8355638.+` <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 <br /> Applicant - Return all copies to Environmental Health Permit/Service`s i601 E.-Haieltbn Ave.,"P:O. Box 2009. Stk., CA 952 _ <br /> CK# DATE PERMIT NO. <br /> FEE AMOUNT DUE. AMOUNT REMITTED <br /> GASH RECEIVED 6Y <br /> INFO <br /> + EH13-24ill 5 <br /> EH W28 <br />