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APPLICATION a.F
<br /> .PERMIT
<br /> -SAN JOAaUIN;.LOCAL�HEALTH DISTRICT
<br /> 1601 E. HAZELTON-AVE STOCKTON, CA re l
<br /> Telephone (2091466-67
<br /> PERMIT EXPIRFS,;� YEAR FROM DALE ISSUED
<br /> Q C� 1 '•
<br /> / lets in Tnplicatel F; :�s' } +' { )'-
<br /> (C,OR1I? - - - ��n1JS�,l./ IICatlbn IS
<br /> Application fart all/p�!np'and the Rules and Regulations of the San Joaquin
<br /> lication is hereby made to the SanCoaqu OrdinanceeNa:549 for.selnr 9 or'No;1862t to truct and/or install the work he c1. ed a This app
<br /> made inrcompliance+nr an Joaqu+n tY s�
<br /> .,- , ,�;1 .I'z � 1, " r i at( :i���d:eC�e j�4�'.r,. � +r ,•, ax s
<br /> tips Oij `� r' bsd 9 Local Health t LSz}e
<br /> ;r � _ , ,� ;� ,: t l.� t•
<br /> CIS
<br /> .fob Address
<br /> _. dress
<br /> Owner's :► _. _..,_... _ ,
<br /> wy
<br /> Phone
<br /> __f License Na.E
<br /> W L -
<br /> Contractor s_Name DESTRUCTION ❑
<br /> _ NEW WELL; ❑ i LRE LACEMENT O
<br /> OF WELLlPUMP: REPAIR ❑ H
<br /> .SYSTEM
<br /> TYPE �..-PUMP
<br /> INSTALLATION , ❑ Y
<br /> OTHER
<br /> QISIANC_E.CO1;NEARES_T: SEPTiCTANK_ _:-_SEER LINE5 —,.DI
<br /> SPOSAL FLD. : PROP. LINE',
<br /> ' AGRICULTURE WELL i
<br /> OTHER WELL
<br /> FOUNDATION
<br /> P
<br /> ITS/SU --
<br /> f Wali Excavation-
<br /> INTENDED;USEj PE OF WELL, PROBLEM ARE? CONSTRUCTION SPECIFIGA710NS Dia 6fWellCasing
<br /> Q Industrial _❑-Open'-Bottom-.;- .O.Manteca it+a• o ions
<br /> i Typeof Casing' _ ut
<br /> ;. p Tracy ,
<br /> omesticlPrNatel ❑ Gravel Pack Do h -- . -
<br /> �.. type, G'- .,
<br /> Spec,scat
<br /> _ m ._..
<br /> ❑ Other Depth of Graut 5sal ro
<br /> r - SPP ❑ Qelta State Work
<br /> ❑ Public , - Eastern --- i_ . Surface-Seal Installed by.
<br /> Irrigation, rox: gepth
<br /> Type of`Pump H.P.
<br /> Repair Work Done ❑ TYP ,+
<br /> , one
<br /> Well D+alneter
<br /> Sealing Material (top 50 1 ;
<br /> } Wel1 Destruction ; ❑ f_.}. Fiiter,Material.(Below 50'1- -
<br /> _. Depth TION❑ (No septic system permitted if public sewer is.
<br /> r ..- i
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITiON'❑ DESTRUC available within 200 feet:)
<br /> ( + Commercial Other — - r
<br /> tnstallatlon will serve Res+deuce ,�. ..". i
<br /> Number of bedrooms
<br /> € Number,of living units. v._ - - a
<br /> a Water t ble depth-
<br /> `- Character of'Sol to a depth':of 3 feett - No. Compartments
<br /> ;❑ •T /Mf'
<br /> ! YPg. 9 G �— Method of Disposal'
<br /> apaaty �°
<br /> SEPTIC TANK `
<br /> PKG TREATMENT PLT-10 c ' Foundation -property Line
<br /> C _ - -Dista! ce'to nearest
<br /> Well
<br /> - + Total length/r.
<br /> :_
<br /> .LEACHING LINE 3❑ No. & Length of Ines property Line-rt
<br /> ❑' Distance to-nearest:: '"_We "" ndat+on —
<br /> : ER BED
<br /> - Well,
<br /> 'Fou
<br /> ,- S Number:
<br /> -...a.. +ze l Nu e
<br /> SEEPAGE PITS ! �,❑ Depth
<br /> SUMPS". Distance to
<br /> -nearest ` Well-, "�
<br /> foundation , Property Line
<br /> DISPOSAL PONDS; ❑ i ;
<br /> �. red this application and that the work;will be dobe in;accordance with San Joaquinjcounty ordinances,'state laws,'and '
<br /> -rules'by certrfy that.! have prepa g _,- - l-
<br /> 31 her m'
<br /> 4 and regulations of the San-Joaquiri-Local-Health District.- - i' I
<br /> to'become s.th e f following.
<br /> ing. a ca compensation lawsofCalrforn+a."Contractors hiring-or sub-oontracting-signature
<br /> ;Home owner or licensed agent's signature cert'rf9es;the followin I cert9fy that in the performance of;the work for which this permit is issued,,!shall no
<br /> +empl'oy any person-in-such manner.
<br /> g: I - bject to workman's compensa,
<br /> certifies the following; I certify that in the performance of the work for which this permit is issued,I shah employ persons su
<br /> E. } .. -%tion laws of California." -r --
<br /> t ,
<br /> f g all for alt required +ns ct+ons. Complete drawing on reverse side. a I
<br /> The applicant ____ `
<br /> T
<br /> Si ned r
<br /> 9 i ICY
<br /> ., R DEPA...._MENT USE ONLY
<br /> l _ t Are
<br /> ol
<br /> ApPhcation Accepted by _ _...:}.. - - r�r�` pate
<br /> 4
<br /> _
<br /> ;Data 1 Final Inspection by
<br /> ;Pit or Grout Inspection by
<br /> �
<br /> � ..
<br /> i.
<br /> IAddrtional Comments:
<br /> Lodi -3621--
<br /> 369t
<br /> "O�Jlanteca ffi3 7104 r ❑ Tracy # ; 3 l
<br /> �- - ':❑ Stk....466 6761-- .. -
<br /> t O Hazeltbn Ave, Box 2009 SI CA 95201,
<br /> Applicanti Return all copies to. Environmental Health ESermrt/5erv+ces 1801E «
<br /> l
<br /> a 9 ; i
<br /> � I
<br /> PERMIT NOT
<br /> E : - ANii]UNT REMITTED• CASH RECEIVED 8Y DATE
<br /> -i FEE `AMOUNT D
<br /> i
<br /> %INFO; ..
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