|
tg
<br /> APPLICATION FOR PERMIT ,
<br /> SAN JOAQUIN'LOCAL'.HEALTH DISTRICT
<br /> 1601 E. HAAL T ON AVE., STOCKTON, 'CA
<br /> "Telephone (209) 466-6781 '
<br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED'` ' ' -' Y
<br /> {Complete in Triplicate)
<br /> i ,� £i . 14 , } i�Or3t.� , r;. ,, w
<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 /> 4 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rgies and Regulations of the San Joaquin
<br /> Local Health District. ? L ,`. r:kq at '1x�a. u r . 1. . . -, - ., ' .� .
<br /> .. .4y�i5 ',l =:.,,3"iF: n.-E�. „" IIF {.9 '• [�
<br /> Job Address 7 E'' l/� r �,LV V�i _ City G� Lot Size PM
<br /> ry�, �$� � #. f'!i:Vit'-� � >; : t. .•�' .�' ` .. . 4 .,�'
<br /> ` t q�
<br /> Owner's Name X71/ //U�`1 Address ' /, � �1�i�5z4!r%� Phone
<br /> J Phone
<br /> Contractor µ. �i r�Address �.. 4m T License No. w,_�
<br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑, DESTRUCTION ❑
<br /> yam; �� s
<br /> PUMP INSTALLATION,,,,❑ SYSTEM_REPAIR_❑-_.„„__,,.,_.-,...,,,...>.–OTHER.❑
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` DISPOSAL FLD. PROP. LINE t T`
<br /> i FOUNDATION AGRICULTURE�WELL^=- OTHER WELL PITS/SUMPS
<br /> INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRIJ6TION SPECIFICATIONS
<br /> 0 Industrial ❑ Open Bottom ❑ Manteca ,. ,t.Dia. of Well Excavation Dia. of Well Casing
<br /> ❑ Domestic/Private ❑ Gravel Pack C Tracy A}Type of•Casing Specifications 1
<br /> Cl Public ❑ Other d Delta Depth of Grout Seal Type of Grout
<br /> ❑ Irrigation �Approx. Depth ❑ Eastern Surface Seal_Installed by
<br /> Repair Work Done ❑ Type of Pump H.P. State Work Done J
<br /> Well Destruction ❑ Well,Diameter Sealing Material (top,50'}mow- �--
<br /> Depth Filler Material lElelow 50'.)
<br /> TYPE OF'.SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is
<br /> available within 200 feet./ {
<br /> Installafion will-serve:*Resi8ence=CommerciaI Other—
<br /> Number
<br /> therENumber of living units: Number of Wpoms .
<br /> Character of soil to a depth of 3 feet: r; c `� "`�,��."7+ Water-table depth
<br /> SEPTIC TANK ❑ 1T a/Mf p L ' G r0l C:f t f-R-Ca aci ;
<br /> YP 9 +'{' p ty' �a (� 0 No. Compartments
<br /> PKG, TREATMENT PLT. ❑ i k. Method of Disposal,
<br /> ;
<br /> a Distance to nearest: Well T_1A6 04.Foundation,___10-i Property Line `7 Q f
<br /> I vkl� i t•
<br /> LEACHING LINE ❑ 'i�lo. & Length of lines ��o `'1��ll 1 --P}'i Total length/size
<br /> I` FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line
<br /> SEEPAGE PITS `❑ Depth 'Si
<br /> ze �! tir Number
<br /> SUMPS, ❑ Distance to nearest: Well ° 'Foundation Property Line
<br /> ` DISPOSAL PONDS ❑ ,
<br /> I hereby certify thati 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 /> f. 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 required inspections. Complete drawing on reverse side.
<br /> Signed>X 6AA0 Title: yl�G g Date: *4
<br /> ! F R DEPARTMENT USE ONLY
<br />)� _ -. '
<br /> - Application Accepted by �- ' - Date �X4.5 107 Area- -
<br /> I Pit or Grout Inspection by Date Final'lnspection by Date r
<br /> r s
<br /> Additional Comments:
<br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385
<br /> Applicant Return all copies to- Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201
<br /> i" FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED'.BY_ DATE PERMIT'NO.
<br /> INFO CASH
<br /> + EH 13-24(fiEV-1/e5) -
<br /> EH 1426 /
<br /> R li
<br /> f
<br />
|