Laserfiche WebLink
4 <br /> APPLICATION FOR PERMITPAY Mesa 1 <br /> SAN 'JOAQUIN LOCAL HEALTH DISTRICT RECEIVED <br /> 1601 E. HAZELTON AVE., STOCKTON, CA MAY 2 6 1988 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMITISERVICES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and, oslall the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. n.� <br /> Job Address J-/^/cs1 L d ✓/LL R4—F l.c�L City 5���� Lot Size PPM <br /> Owner's Name -��CAt.� ?AD? �7D Address'16�1I-11JCa�G�C'f�MZ z Ste ~Phon(P) AT. Zip <br /> ContractorL��tiflt _tAAkMAFAddress 303-4 �S / �OVri License No. P n,$) <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHERA .Si)lL J5z9a JbS <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. PROP. LINE _/_-� Fr <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial El Open Bottom ❑ MantecaDia. of Well Excavation Dia. of NPSIl: <br /> O Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I1 Public ❑ Other 0 Delta Depth of Grout Seal Type of Grout JcQ!1ra_r__. <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done 0 t Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> X 54li $D)24i,,3$ Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wi serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE / 0 No. & Length of lines Total length/size <br /> FILTER BED /v A' ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS �/T L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all equired inspections. Complete drawing on reverse side. <br /> Signed X �'� Title: ��fi !- / Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date� At <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ i4i 369-36210 O Manteca 823-7104 0 T cy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> •.EH12-2x(REV.r i x 51 <br /> EN a-14 <br />