Laserfiche WebLink
� r <br /> APPLI-ATION FOR PERMIT <br /> SAN'JOAQUIN LOCAL HEALTH DISTRICT v ; <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (2091466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ° t, <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is ..': <br />` made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1952 for well`pump and tis les and Regulations of the San Joaquin <br /> Local Health District. <br /> M <br /> city of sire , <br /> JO,Address <br /> Q� ddress Phone <br /> Owner's Name a3 <br /> �v t�9'ress License No.�L Pto>�9,faa f .?} <br /> Contractor '_'41 <br /> TYPE Of WELLIPUMP: NEW WELL 0 WELL REPLACEMENT U DESTRUCTION ❑ <br /> J k , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER 13 ' R <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE V�.. <br /> ^� FOUNDATION AGRICULTURE WELL OTHER WELL PITSi SUMPS A <br /> m INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS •r, <br /> Ll Industrial Cl Open Bottom g Manteca Dia. of Well Excavation Dia.of Well Casing Af <br /> r.- <br /> f7 DomesticlPrivate n Gravel Pack ❑Tracy Type of Casing Specifications - <br /> `sea, <br /> 1 I•I Prlblic VI Other f3 Delta Depth of Grout Seal Type of Grout <br /> f.^.. <br /> k1 1 Irrgtalron _-_.Approx. Depth I I Eastern Surlace Seal Installed by - <br /> ' Repair Work Done 13 Type of Pump H.P. - State Work Done <br /> 0 r <br /> .� Well Destrutt;nn E 1 Well Diameter Sealing Material(top 50') <br /> Depth Filler Material 11816tow 501 r»t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IA REPAIR/ADDITION DESTRUCTION I 1 INo septic system pemtitted if public sewer is * <br /> f available within 200 feet.1 k . <br /> r r <br /> 't Installation will serve: Re&tence_ Conin iat— Other f <br /> i1 <br /> Number of living units: Namber of bedrooms <br /> Character of soil to a depth of 3 feet: Wates table depth <br /> Capacity No. Compartments <br /> SEPTIC TANK 13 Type/Mfg <br /> lf Di <br /> Method oDisposal <br /> } PKG.TREATMENT PLT.I.1 Met <br /> j Distance to nearest: Well Foundation Property Line -.'i• <br /> LEACHING LINE i1 No.6 Length of lines - Total length/sl:e ,-- <br /> Foundations Property Line <br /> y FILTER BED I I Distance to nearest: W x <br /> SEEPAGE PITS I t Depth . - - Sire Num4ar <br /> SUMPSI I Distant to Well Founds' n Property Line <br /> DISPOSAL PONDS l 1 1 "C'� <br /> I hereby certify that I have prepared This application and that the work will he done in accordance with San Joaquin county ordinances,state laws,and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Hoe owner or licensed agent's signature certifies the following:"I Certify that the orrnencs of tet work for whlth this permit is issued, I sltae <br /> Horne M perf <br /> not " {r <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature e'� <br /> i certifies the following:"I certify that in the parfoltimme of the work for which this permit Is issued,1 shall employ peraorm subject to workman's compena <br /> tion laws of California." <br /> The applic t Call for aawgetiro actions. mplete drawing on"mom side. <br /> Signed X Date: <br /> FOR DEPARTMENT USE 014LY � f <br /> Applic Accepted by d, ^�- -�=�----- - Date + Area L, . <br /> ��f at ��� Final Inspection b z� _� D e <br /> Grduf In�tion by v <br /> Additional Commems: , <br /> i-1 Stk 466-6781 C. Lodi 369-3621 0 Manteca 823.7104 0 Tracy 635-6385 <br /> Applicant•Return all copies to: Environmental Health Permit/5ervkes 1601 E. Haretton Ave., P.O; 80112009, Stk., CA 95 � ! ' ,40 <br /> — <br /> ftE A*nollrYt OLI AMOUNT REMITTED It RECEIVED OY GATE *PERMIT No, <br /> IWO ^ CASH <br /> 1H'7'�tArv,� w�, 7o�VGI �G►��Is_ ���- ..� ,} /."VIr g�'L �K / <br />,. fH 1� <br /> .pY,ate: <br />