Laserfiche WebLink
Telephone 1209) 466-6781 •• t� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ei4VIRUtJENTAL HEALTH <br /> (Complete in Triplicate) FERMIT/SERVICES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or.nutall the work herein described.TWO application is <br /> made in compliane,with San Joaquin County Ordinance No.6/9 to,saw ps or No. 1862 for woupump and the Rules and Repuatieets of the San Jpaquln <br /> Local Health Dalrict. ^ <br /> ��� ys/r // , <br /> Job Address ��—�/d! Cita-St Sia__ PM <br /> r <br /> Owner's Name bitim �/(tl�Lasy `• J CD E.[2.� _ Pho <br /> Contractor Address �♦✓ IBX ��27 License No. 16?323Phone v <br /> TYPE OF WELL/PUMP: NE WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR CY/ OTHER O <br /> DISTANCE TO NEA#STi SEPTIC TANK SEWER LINES DISPOSAL FLD.__ PROP. LINE <br /> II � FOUNDATION AGRICULTURE WELL OTHER WELL PITS(SUMPS _ <br /> INTENDED USE i TYPE OF WELL PF106LEM AREA CONSTRUCTION SPECIFICATIONS <br /> O aduat W O'Oi7on Bottom ❑ Manteu Du. of Well Excavation Dia.of Well Casing <br /> O Donauic/Private I O Grnal Pack ❑Tracy Type of Casing_ __ Specifications <br /> I'i Pubko 11 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrrpatton ✓ _Approx. Depth I I Morn Sud a Seal Installed by <br /> Repair Week Dora LS Type of Pump H,P. State Work Dona <br /> Welt Desumuon 4J Wait Diameter Sealing Material Itop 601 F <br /> Depth Filter Malarial(Below 601 ' <br /> TYPE OF SEPTIC WORK; NEW.INSTALLATION 1 I REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public"war is <br /> ���L I�� available within 200 feet.) <br /> Installation ":tion w : RealdleT"_ Commercial_ Other <br /> Number of"delta:— Number of bedrooms <br /> Character of aoi to,a depth of 3 feet: Water able depth t,^ <br /> SEPTIC TANK 0* Typo/Mfg Capacity. No. Compannents •`�, <br /> PKG. TREATMENT PLT.❑ , Method of Disposal <br /> Dialance to national: Wag Foundation___ Propeny Line <br /> LEACHING LINE' LI No.a Length of lines _ Total length/sue <br /> FILTER BED EI Distance to(health: Well_.___- Foundation Property Lire <br /> SEEPAGE PITS I I Depth Sia _ ._ Number <br /> SUMPS LI Distance to mast: Well Foundation Propend Lina <br /> DISPOSAL PONDS fl <br /> I hereby tinily that I have prepared this application and that the work will be done in accordance with San Joaquin county onlauence t,sate awe,and <br /> runs and regulations of the San Joaquin Local Health Disitim <br /> Home owner a titan gnatum cant' the following: "1 unify,that in the performance of the work for which this permit is owed,1 shall not <br /> employ any pawn such man lee lost urbjec orkman's rgmlzansatwn laws of California."Contractor's haring or wtruntractmp signature <br /> certdas the loco :"I certify at' Iha of a work for which t permit is issued,I shall employ persons subject to workman's cornpanea- <br /> •ion laws of Cali mile." <br /> The applicant r all uirM m e drawn on rev <br /> M e <br /> Signed % B Title: Q�Date: <br /> �J FOR P gTMENT USE ONLY <br /> �' _C��\ r� e�l Date — Area IL t <br /> Application Accepted by / fir.- 1 <br /> Pit or Grout Inspection by ;—/c Data Final Inspection by Date i,1 <br /> Additional Comments: — <br /> i.: Silk 4666781 O Lodi 369-3621 Ci Manteca 823-7100 ❑ Tracy 8366386 <br /> Applicant - Return all copies to: Environmental Health Pumit/Santee 1601 E. Hazelton Ave., P.O. Bos 2008, Stk., CA 86201 <br /> rFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED fly DATE PERMIT N0. <br /> INFO (/ <br /> • EM la la(REV <br /> EM la 21 � <br />