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_ _ _ .. ... 'i• .- . _. , ,. n i.:'y:. .. �.a,ls•.,. \.:. . •�', �t� .:,XY..'r. tia_.i:: �'r <br /> • ,, -. ';t Wit: <br /> ;t <br /> - L <br /> APPLICATION FOR PERMIT <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 /> Application h hereby made to the Sm Joaquin Local Health District for a permit to construct and/or kutall the work herein described.This application n r <br /> made in compliance with San Joaquin County Ordinance No.649 for sewage or No.1862 for well/pump and the Rufen and Reguletkns of the San Joaquin <br /> Local Health District. :: •,;. ; ,. <br /> City-T Lot Size /w�f' PM n <br /> Job Address r. <br /> Owner's Name Fy�sTT <br /> Address <br /> '�— - ... _Phone <br /> Phone -f'1.TJ- <br /> Sv--Llcense No. ,. <br /> ..ContrarctOmNar+ DESTRUCTION O <br /> TYPE LUr.;:eP: 1 N WELL O WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR 13OTHER ❑ a <br /> DISPOSAL FLD. PROP.LINE <br /> j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PRS/SUMPS t• <br /> INTENDED I!SE TYPE OF WELL PROBLEM ARFA CONSTRUCTION SPECIFICATIONS <br /> O Open, - O Manteca Dia.of Weil Excavation Die.of WeU Casing. <br /> ❑ Industrial SpecMeatim <br /> O Domestk/Private. O Gravel Pack ❑Tracy Type of Casing - <br /> p Public O Other O Delta Depth of Grout Seal Typs of Grout W <br /> I. 1' <br /> a O Irftetion -Approx.Depth ❑Eastern Surface Seal Installed by - <br /> Repair Work Done D Type of Pump R.P: - - Stats Work Done <br /> Seafing Material(top 60') <br /> Wall Destruction O Well Diameter O f <br /> Depth Rller Material(Below 60) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION DESTRUCTION O availabpe'wi him 2(l0 feet.) rt public sewer is i <br /> r k. <br /> r'_Installation wh,sane: Residence L_Commercial_ Other %/e/jeiv f liAvNe�r�y <br /> r <br /> Number of living unks:_ / Number of bedrooms <br /> CNersetix of soil to a de,tlt of 3 isut• L%�bT �.OA/"/ Water table depths <br /> SEPTIC TANK 10. Type/Mfg <br /> Capar'D . No. Compartments x <br /> cityljg <br /> Method of Disposal <br /> PKG.TREATMENT PLT.D ; !Ar** Foundation /o' Property Una — v <br /> ri Distance to nearest: Well <br /> kF <br /> �f Total length/size - <br /> LEACHING LINE Z No.&Length of linfm O, Line <br /> RLTIDi BED ❑ Distance to nearest: Well_7S Foundation ProPam R [ <br /> Number <br /> SEEPAGE+ S� ❑ Depth Size <br /> Foundation Property Line <br /> SUMPS"""r ❑ Dbbncetto nearest:' Well --- - ., <br /> DISPOSAL PONOS D <br /> I hereby certify that I have prepared this applicatio "an'that,he work will be done in accordance with Seri Joaquin oourrtY ordinances,-to Iowa.and <br /> te <br /> rules and regulations of the Sen Joaquin_Local Health District. <br /> Home owner l Pions of agent's signature certHies the following:"I certify that in the performance of the Irk for which this'pennit is issued,1 shall r • <br /> employ any person in such manner re <br /> as to became subOO to workman's compensation laws of Califomia."Contractor s hiring or sub-contracting sig <br /> 1 1 that In the performance of the work for which this permit is issued,I shall employ persona subject to workman's comp ensa- .? { <br /> certifies the following:" certify _. _. . <br /> --tion laws of Cal'rfanis:' <br /> r <br /> ' The applicant must for all required inspections.Complete <br /> on reverse side. <br /> Title: Date r + <br /> �I Signed X_ . <br /> _- <br /> FOR DEPARTMENT USE ONLY <br /> pplfeation Accepted by Date <br /> AAfOa ` . <br /> :. —�7 <br /> - � Date Final Inspection by <br /> 7 DOW <br /> Ph or Grout Inspecdon by _. .. _ <br /> Addi6onsl Comments:486 a <br /> - tlt 6781 D Lndl 369 3521 O Manteca 823.7104 ❑Tracy 8364= <br /> ;O S ' <br /> pppUctnt-Return all copies to: Ertviratnxntal Health Pemttt/Services 1601 E.Hazelton Ave..P.O.Box 2008,Stk,CA 96201 ~ <br /> FEE AMOUNT DUE <br /> AMOUNT REMITTED CASW <br /> RECEIVED BY LATE PERMR NO. <br /> t INFO r <br /> •BIt1]/111EV.70/01 — ..c. _._. _ .. _. . .. ��13•• $.5`� ._ _ <br /> L 1N/_ -__ --"a'wrfe�adQk'tyk�"'^y..k1S:":i!'•��iy�`I'ifi+'M•, �..�;.•< � �%+F c.�2�-'.-r.t- 'yr - ....ia e24.s::,�+ .,i.� e.^�'f�`..�I•: f.�.. � <br /> i <br /> M1. <br />