Laserfiche WebLink
~ APPLICATION FOR PERMA's' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) _ <br /> described.Thin <br /> is <br /> Application is hereby made to the San Joaquin Local Health District for a Permit ar No. Construct for welt// mp and?the Rules and Reguletidr d Ban Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage pu <br /> u Local Health District. <br /> r L <br /> City MT4 R Lot Sim %" <br /> Job Address <br /> / r <br /> • a 3 s/ 9 G.a��.1 Phor» _ <br /> Owner's Name Address <br /> Contractor /Y .l /�` GGA_Andress / License No. 21A <br /> Contractor <br /> P110Aa' W <br /> LJ <br /> OTHER <br /> 'TYPE OF WELL/PUMP: NEW WELL ZWELL REPLACEMENT C DESTRUCTION <br /> SYSTEM REPAIR 13OTHER C PUMP INSTALLATION ❑ <br /> DISPOSAL FLD.� PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> AGRICULTURE WELL — OTHER WELL PETS/SUMPS <br /> FOUNDATION _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia.of Wap CaWrg <br /> u Industrial ❑Open Bonom [L Manteca Die.of Well Excavation Specifications <br /> ❑ Domeatic/Privets O Gravel Peck ❑Tracy Type o1 Casing <br /> i <br /> 7— Public ❑Other O Doha Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth E: Eastern Surfs"Seal Installed by <br /> g Stats Work Duro <br /> Repair Work Done E: Type of Pump H.P. <br /> - Well Destruction ❑ Well Diameter Sealing Material(top 50.) <br /> Depth Filler Material(Below 60) <br /> _ WORK: NEW INSTALLATION❑ REPAIR/ADDITION DESTRUCTION❑ <br /> V. TYPE OF SEPTIC IM feel.) d public sewer Y <br /> Installation will serve: Residence, Commercial_ Other - <br /> _,..i Number of living units:--/— Number o1 bedrooms — <br /> Water able rlepdt <br /> Character o/soil to a depth of 3 feet: <br /> _ SEPTIC TANK ❑ Type/Mfg No.Compermwtb <br /> ._ CapecM �- <br /> PKG.TREATMENT PLT.O 4�CtT _� Method of Difposal <br /> Distance to nearest Well :oundadon Property Lim � - <br /> G / <br /> LEACHING LINE ' No.8 Length of lines �'� � Pte' Total brplh/size CO <br /> f FILTER BED C patience to neatest Well 9&0— Foundation 4:F Property Lim <br /> SEEPAGE PITS ❑ Depth Size Number <br /> 7 SUMPS ❑ Distance to nearest: Well Foundation Prop"Une <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 knees,and <br /> h rules and regubtiom of the Sen Joaquin Local Health District. <br /> Home owner or licensed egem's signature certifies the following:"'1 certifym <br /> that in the peffoon"of the work for which this penrit b Issued,I shell not <br /> empty any person in such manner as to became subject to workman's compensation lows of Calied.I shelf <br /> Cploy tero/s s,subject <br /> or fah-cpnbacBrg dgnauna <br /> "rtiTM the blowing:"1 certify that in the performance of the work far which this Permit <br /> is Issued.I shs0 ampby perams fubjwt to wRsrknterh's CtatlpaMF <br /> tlon laws of CalRomis.'- <br /> 4 The applicant must call forty M7 I inspeccttip Complete drawing on reverse =2=side. � <br /> /J! /.!2s Dsta: <br /> f^. <br /> 7- <br /> Signed.. <br /> } - FOR DEPARTMENT USE ONLY <br /> Date A.y <br /> Application Accepted by <br /> S N D.t.3BS <br /> Ph or Grout Impaction by Date Final Inspection by <br /> 4 <br /> Additional Comments: <br /> t O Stk 4686751 ❑ Ladi 3fiB3621 Manteca 871-7104 ❑Tracy 8158M <br /> y' <br /> Applicant-Return all copies tp:Environmernal eahh Pemet/Services 1601 E.Haxalton Ave.,P.O. Box 2(108,Stk., CA 95A1 <br /> 1 <br /> FEE r K e RECEIVED BY DATE PERMITND. <br /> IRV INFO AMOUNT DUE AMOUNT REMITTED GSH <br /> + <br /> E. <br /> i <br /> I _ <br />