Laserfiche WebLink
D <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL'H EALTH DISTRICT UU 0, <br /> 1601 E. HAZE TON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES I YEAR'FROM DATE ISSUED <br /> I 7-- <br /> (C6molet6 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 it <br /> made in compliance w!'th.San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ru. <br /> -+Lles and Regulations of the San Joaquin <br /> Local Health District <br /> 4- <br /> '"333 <br /> 21 <br /> Ciit;'�5-4 *7 Lot! <br /> Job Address t1?(- Wes ('-,o f er 6 <br /> Owner's Name Address Ve s-.;n-6 Cru Z• Phi,,, q08—q6Z 18 70 <br /> Contractor b5s 60) Address 635 W_ 6 ta IL, <br /> -5-/- 411. License No.33*5309Ph,n, <br /> ?Yf-43® L <br /> TYPE OF WELL/PUMP: NEW WELL El WELL-REPLACEMENT 1-1 DESTRUCTIONX <br /> PUMP INSTALLATION El SYSTEM REPAIR 0 OTHER 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial CI Open Bottom 11 Manteca Dia. of Well Excavationasing <br /> Dia. of Well C <br /> Ll Domestic/Private El Gravel Pack4­1.1 EJ Tracy Type of Casing Specifications <br /> r <br /> D Public 11 Other <br /> z-1.1 I . E3 Delta Depth of Grout Seal Type of Grout <br /> El Irrigation ___!Approxi'Depth El Eastern Surface Seal Installed by <br /> Repair Work Done E)' Type of Pump t H.P. State Work Done <br /> Well Destruction C3, Well'Diameter Y Sealing Material {top 501 <br /> Mi Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITIONLJ DESTRUCTION [] (No septic system permitted if publicsewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial 'Other <br /> Number of living units: f Number of bedrooms <br /> Character of soil to a depth:of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments <br /> PKG. TREATMENT PLT. D 1 .1 Method of Disposal <br /> Distance to nearest: Well .,Foundation Property Line <br /> LEACHINGLINE '0 N i o. & Length <br /> gth of lines Total length/size <br /> ...FILTER BED 0 Distance to nearest: Well. Fouhdation— Property Line <br /> SEEPAGE PITS C1, .'D pth Size Number <br /> SUMPS 11 'Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 1 1� <br /> I 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 per <br /> �,90 n in such manner as to become subject to 'workman's compensation laws oi,,California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that <br /> hat in the' ' rformance of the work for which this permit is issued,ue all employ p6rsons subject to workman's compensa- <br /> tion laws of California.":. <br /> The applicant mu t"Il for all req 'red ineDe I c-tions. Complete drawing on rev rse side. <br /> Signed <br /> ;1 Title: Date: j1(, Z7 <br /> 7 <br /> FOR DEPAR ENT USE ONLY <br /> Application Accepted by Datej�nZ'7-rr Ar.a <br /> Pit or Grout Inspection <br /> qng <br /> Date 1� Final Inspection Date <br /> Additional Comments: <br /> ❑ Sik-46ff-76781 ❑Yr_a_cy__83&b3Z-- N"""T""""' <br /> Applicant- Return all-c6pies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Elox,2009,tik�:CA 95201 <br /> 4- <br /> INFO <br /> AMOUNT DUE -AMOUNT REMITTEDCWRECEIVED BY DATE. PERMIT"NO. <br /> R <br /> +EH 13-24(REV.1 8 J <br /> EH 1426 <br />