Laserfiche WebLink
y'e <br /> APPLICATION FOR PERMIT <br /> SAN JCAQUIN LOCAL HEALTH DISTRICT ;F <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Ccmplete in Triplicate) <br /> Application is hereby:na.`e to the San Joaquin Local Health District for a permit!o 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. 1962 for we;Upurnp and tite Rules and Regulations of the San Joaquin <br /> Loral Health District. <br /> .Job Address _��8i1��%II•�4��LL-r1 �-1--------- City�./��«/s IlC c�Lot Sue- --- NM-/--- <br /> 5.� r LVGQ T1r� �- Phone <br /> Owner's Name L_. Address <br /> � �. -� &8 <br /> 1/LYYeS ` -Address/177 Yya�� 64-41icense No.�4 a�_PhoneC � <br /> Con!ractor ...__ . Wc- _ <br /> TYPE OF WELL/PUMP: NEW WELL ! WELL REPLACEMENT i_' DESTRUCTION C `\• ' <br /> PUMP INSTALLATION L; SYSTEM REPAIR : OTHER K]' <br /> �'•. <br /> DISTANCE TO NEAREST: SEPTIC TANK -___- SEWER LINES __--_.__- DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL _ ._ OTHER WELL-- PITSISUMPS -_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS <br /> C Industrial C Open Bottom i :Manteca Dia. of Well Excavation._-_ Dia.of Well Casing -- <br /> 'Domestic/Private ❑ Gravel Pack Tracy Type of Casin _-_-- -. Specifications <br /> Public C Other Delta Depth of Grout Seal _---.-_ Type of Grout - <br /> t <br /> i� taw Work <br /> -Approx. Depth Eastern Surface Seal Installed by___--.-- - <br /> k <br /> Repair Work Done Type of Pr, n ���__ H.P. L._-_.__—_..--._ Sj <br /> / Do- a,'��• _ <br /> Well Destruction .: Well D.ameter _._-___.- Sealing Material(top 50'1 .f4S_—! _(-. <br /> Depth ___ _ Fille'Material(Below 501 - — <br /> 1"YPE OF SEPTIC WORK: NEW INSTALLATION! : REPAIR/ADDITION i DESTRUCTION ' (No septic sys:am pe:mitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence-- Commefrial..-_._ Other <br /> Number of living units:_--- Number of bedrooms.------ <br /> Character of soil to a depth of 3 feet: -- --.-..-.-- --_----- ----- - -- -------Water table depth <br /> Character <br /> TANK L, TypeiMfg --._-_-._._-..__- ----------. Capal.ity--..._. .___.-. No. Compartments - <br /> PKG.TREATMENT PLT.: Method of Disposal - , <br /> Distance to nearest: Well -_._-__ Foundation .____- _ Property Line <br /> LEACHING LINE (7 No. & Length of lines .. --.____-__--. _ _ - Total length/size ; <br /> FILTER BED = Distance to nearest: Well -..-_.._-_ Foundation------­ Property Line <br /> SEEPAGE PITS Depth _._--Size __.-.._ _- -- Nwnber_ --- \ <br /> SUMPS =. Distance to nearest: Well--___-__. Foundation _ Property Line ti <br /> p'. <br /> DISPOSAL PONDS <br /> 1 hereby certify that I have prepared this application and that the work wi:l be donp in accordance with San Joaquin county ordinances,state laws,and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Nome owner or licensed agent's signature certifies the following:"I certify that in the performrnce of the work for which this permit is issued. I shall not <br /> en-,-Ioy any person in such manner as to become subject to workman'r c,)mpensatior law;of California."Contractor's hiring or suh-contracting signature <br /> certifies the fnllowing:"I certify that in the performance of the work for which this permit is issued,I shall en,ploy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicWntst call for all required inspections. Complete drawing on rev Cse side. ,I <br /> / ) z <br /> Signed <br /> FQR DEPARTMENT USE ONLY <br /> rrL�li ---— -- —' — Date 1Q. __��lArea <br /> Application Accepted - �- - .,. 'V <br /> "Date: r-SCS : <br /> Pit or Grout Inspecti _ _- Date_------------ Final Inspection by <br /> Additional Comments:? <br /> E Stk 466.6761 � Lodi 369-3621 Manteca 8237104 :.: Tracy 8A6385 fL,, b► <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Ha:ettcn Ave.. P.O. Box 200x, Stk., C = <br /> r' <br /> FEES' RECEIVED BY DATE PERMIT N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASN t-. <br /> .EN 1324 IREV - jam. ,C•..7 �:G '2 (, i\> r� 1 <br /> EH i4 26 <br />