Laserfiche WebLink
F <br /> S' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> }A E A <br /> 1601 E. HAZES i�ON,AVE., STOCKTON, CA " "'EIV" D, <br /> Telephone (269)'466-6781 DEC 6 1989 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) VIRO. IMENTAL. HEALTH <br /> A ami- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worAiTag pp6cation 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. /y <br /> 44 --- :MovoJ4u1.� .. City �� e PM <br /> c-�;L <br /> Job Address l j� g — )L1Y <br /> �� 1 i Gi Address A Q�" ' � Mo d1a � Phone <br /> Owner's Name r <br /> a 66 6 z <br /> Contractor <br /> ` Q `� License No,! b 3�Phone <br /> �- ss <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ° <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public (7 Other n Delta Depth of Grout Seal Type of Grout <br /> t, E <br /> I I irrigation Approx. Depth l astern Surf a Seal Installed by <br /> Repair Work Done {lam Type of Pumps H�.e:, State Work Done_ �✓ <br /> p .F" V :. <br /> WeII_P.estructiort,. _❑—�Wel1_Diameter Sealjng,Mate6aI-(top.50:},. -- — - -- <br /> } � <br /> Depth � � Filler Maie�ial��,Bt3tovv 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION1Y-li-,.DESTRUCTkION I 1 Mo septic system permitted if public sewer is <br /> j -_ 3 available within 200 feet.) <br /> Installation will serve: Residence ff Commercial_ Other <br /> Number of living units: Nuiriber of bedrooms Z"S <br /> Character of soil to a depth of 3 feet:# �y� t`• Water table depth <br /> SEPTIC TANK ' ❑ Type/Mfg "' � � `� .Capacity k � No. Compartments <br /> PKG. TREATMENT PLT. ❑ ay " f� Method of Disposal r <br /> Distance to,nearest%�' Well Foundation ) + Property.Line <br /> LEACHING LINE ❑ No. & Length of tines 4i. Total length/size <br /> FILTER BED El Distance to nearest: Well .' FountlaUon? Property Line <br /> E SEEPAGE PITS l I Depth Size * „ i [ Number <br /> SUMPS ❑ Distant a to nearest: Well�F'r r t( x' 'Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> F I hereby c ve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules regulations of San Joaquin Local Health Di?:trict. <br /> Ho owner or licensed ag is signatur ce Ties the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> e ploy-any person in suc nner ats-t e u ect..to-workman's= a anon-laws of California."Contractor's hiring or sub-contracting signature <br /> rtifies the following: "I ify th in a ma a of the'wor r Ury <br /> p mit is i ued, I shall employ persons subject to workman's compensa <br /> on laws of Califo nia.' <br /> he applic mus or all uir tic :Compi a drawing do. <br /> � Date: � • <br /> Sig X Title: _ <br /> s OR DEPARTMENT USE ONLY ' <br /> -/� Or <br /> Application Accepted by Date Area <br /> Pit or.Grout Inspection by Date Final Inspection by Date r!l „ <br /> Additional Comments: <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> k� f <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 411 CASH RECEIVED BY DATE PERMIT"NO. ry <br /> INFO <br /> 1 <br /> +.EH 13-24 1AEV.1 i n 5r Q <br /> F EH 1428 <br />