Laserfiche WebLink
j.^ - `» - r�,J� til: �p - .. t '-- _-- _ ,_r•.�,:� -+.r <br /> 10.00 #4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> e <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.1862 forwell/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. c <br /> Job Address �7 t� � Ci4!1i Lot Size l PM <br /> Owner's Name�e�[ 04"A-Y!t 64;11 Address �/ 7r C Phone if <br /> Contractor's Name �ti rJi�I . License No. J �- � y Phone J <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT G DESTRUCTION;-13- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER D j r} <br /> DISTY>NkE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �J <br /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE't s(TYPE�OF WELL7:�iM AREA C RUCTION SPECIFICATIONS <br /> r <br /> ❑ Industrial DOp <br /> e <br /> n <br /> Bottom <br /> .::3 Dia, of Well Excavation Dia_of Well Casing <br /> ❑ DomesticJPrivate D Gravel Pack of Casing Specifications 1 f <br /> D PubliicG Other Depth of Grout Seal _ Type of Grout <br /> C Irrigation --Approx. Depth D Eastern Surface Seal Installed by <br /> 1 Repair Work Done G Type of Pump H.P, ! State Work Done <br /> Well Destruction D Well Diameter Searing Material4top <br /> } Z <br /> 6 Z-1 Depth Filler Material(Below 60' <br /> TYPE EPTIC WORK; :NEW I STALLATIO REPAIR/ADDITION D DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) 1 <br /> Installation will serve: Residence._ C merci5F_ __ Other 6 , <br /> i Number of living units:Z__ Number of bedro i <br /> Charallr)of�soil to a depth of 3 feet: <br /> i Water table depth i <br /> SEPTIC TANK-'+•f Type/Mfg7t=enit T ?—h zli 2- — Capacity �� No. Compartments <br /> z PKG. TREATMENT PLT.❑ - <br /> r Method of is osai �\! <br /> ! ti Dist a to nearest: Wsll Foundation Property Line f—M1 <br /> LEACHING LINE /101S <br /> No. & Length of lines �otal length/sze A <br /> f <br /> FILTER BED ❑ Distance to nearest: Well_S Foundations Property Line O <br /> s <br /> SEEPAGE PITS Depth 4 Size IrN Nu ber <br /> SUMPS D �tstah'ce-to-nearesr.- Well .Founcdatian,J� Property Line _ <br /> DISPOSAL PONDS ,-.p,,,,A I <br /> i I hereby certify that I have prepared tpis app)ica3 n anti that the'vZM'av-Wbe done in'acoordance with San Joaquin county ordinances,state laws,and } <br /> I rules and regulations of the San Joaquin-L'ocalrt(ealth bistrict. f <br /> Home owner or licerisedlagent's,spp;tTlre certifies the following: f'. <br /> 1 employ any person in su�h�nann�r as'to'become subiect to workman's compensation laws oof Califormance rnia."Contracwwork for rs'hhiirinch g permit is issued, I shall not t <br /> ng or sub-contracting signature <br /> certifies the followin "lice i pe employ persons subject to workman's compensa- <br /> � - rtlfy that in the performance of the work for which this permit is issued,I shall em to <br /> tion laws of Califor <br /> i "' ,rte: <br /> { The applicant m r all red Inspections. Complete drawing on'F' ase' <br /> y ; Signed <br /> Date: <br /> ;t DEPARTMENT USE ONLY f <br /> { tion Accepted by <br /> Data ` Area l <br /> 1 % FiPit r Grout Inspection byAM Data T <br /> nal Inspection, T Date <br /> Additional Comments: <br /> D Stk 466.6781 D Lodi 3621 O-Manteca-!-8237104-----o-Trky--83F>'S gg— ------- - <br /> Applicant- Return all copies to: Emifonmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., GA 96201 <br /> i <br /> 1 <br /> !MFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> ¢ <br /> E,4-26 IRS.,a,a3, ­70- 00 /a , ltilp <br /> , ze <br />