Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON. CA <br /> _ Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ <br /> (Complete in Triplicate) <br /> Application is Mneby made to the San Joaquin Local Health District for a permit to construct arM/or instal the work herein described. This application is <br /> made in compliance with San Joaquin Coonry Ordinance No 549 Im sewage or No. 1862 for w,illpump and the Rules and Regulations of the San Joaquin <br /> Local Health Disrnct. <br /> C 11 ��ay� �'N&jh4 k1@ Lot Size PM <br /> Job Address _�Y � ' u-�-r+'-'-���--'— City <br /> 1 <br /> P <br /> 1 Address _ ltorw <br /> Owner's Name _ mrrtu�.L�2fJ- �� ,A,.v C , <br /> -fr S2- <br /> Contracts 1 Address y.i�esy "SNI License No.a'7 Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENTQ DESTRUCTION 0 <br /> _ STEM REPAIR 0. . .. - — OTHER ❑ <br /> _P _ -- <br /> UMP-INS7ALLATKON.O - ---5`( <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK T— <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Wel Casing <br /> _<_60p,.-g0(Iplrn'�--❑ Manteca Dia. of Wel t:x avation <br /> [] industrial $ ciltcations <br /> O Dunestic/Private U Gravel Pack ❑Tracy Type of Casing Pe <br /> (1 Other n Daha Depth of Grout Seal Type of Grout <br /> M Public if _ <br /> I I Irrgabon _ Appro t. Depth I I ESMa Surface Seal Instalbd by -- <br /> I1` Repair Work Done C1 Type of Pump H.P. State Work Dune <br /> y. Well Destruction ❑ Wen Diameter Sealing Material Itop 50'1 <br /> i Depth i t Filter Material Mellow 50'1 <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic ayslem permittedd public sewer Is <br /> aysaeble vnthin 200 feet.) <br /> Numberon will serve: Resi11dence Commercial-3th.r .{ <br /> Number of living units: �1- Number Of bedroonta / <br /> s ncl`� iM - Water U <br /> epth <br /> Character of wN to a de�ptl/w.h3 feeC• __ <br /> SEPTIC TANK q" Type/Mfg Capacity IZh A No. <br /> PIG. TREATMENT PLT. ( I Met <br /> 1 <br /> t <br /> Dista to rnearest: Well J.S1Sr=— Foundation 'I D Property LLEACHING LINE yr No.-B length of Ines ' d Total length/size - °+ Foundation 1 Prop6 y FILTER SED ❑ Distance to nearest: WeB�— --.��—SEEPAGE PITS I Depth _ Sae - Number -�r. <br /> SUMPS T am' Ll Distance to nearest:— -Well ____ Foundation _-_ Propail - <br /> 1 DISPOSAL PONDS ❑ <br /> I hereby ily that i have prepared Misapplication and that the work will be done in accordance with San Joaquin county ordinances, state lows, an <br /> cenit <br /> rules and regulations of.the San Joaquin Local Health Dikinct. <br /> t Home owner or licensed agent's signarore certifies the following: "I cadity,that in the performance of the work for which this permit is issued. I shall not <br /> I employ any person in such manner as to become wbject to workman's compensation laws Of California,"' Contractor's biting or sub contracting Signature <br /> ,ar,fiws the following:"I certify that in the performance of the work for which this permit is ISwed. I shall employ persons subject to workman's compsnse <br /> tion laws of.Caklornia."i-+ <br /> The applicant must"it for-all r uired Inspections. Complete drawing on reverse side. _ <br /> �r f D- - 41 <br /> Signed % � <br /> ,n/ _- Title: n�aLzz-- -- Date: <br /> DEPA ENT US ONLY / <br /> Application Accepted by Date/ W <br /> Pit or Grout Inspection by — Date Final Inspection by Data — <br /> i <br /> Additional Comments: <br /> G Sir, 466.6781 C Lodi 3693821 ❑ Manteca 023-7100 ❑ Tracy 835-6385 <br /> Applicant Rswm all wpm to: Environmental Health Parmn/Services 1801 E. Hazelton Ave., P.O. Bos 2009. Sill., CA 95201 <br /> FEE .AMOUNT DUE AMOUNT REMITTED C REDEIVEO BV GATE PERMIT NO. <br /> INFO CASH <br /> r EM n4at <br />