|
APPLICATION.f R,PERMIT
<br /> SAN JOAQUIN;:LOCA'L.HEALTH DISTRICT 5-7
<br /> 1601 E. HAZEL T;ON-AVE., STOCKTON, CA 41U,
<br /> e_ ..
<br /> � 7elphon�e (209)-466-67 81
<br /> i i-�r�. -^art, � st -} Y r� r!`�i '° ! 1 �•^ � brY i"]��" i� ��'6»,".� i�: iiJ '" e,l YF/t
<br /> PERMIT EXPIRES,I.YEAR FROM DATE ISSUED,
<br /> inAT0plicAte?. �b i�t:}w.'y�,i.� .�r l�til!""!r YisFC;
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herelh describe&T1,46'applidation is
<br /> made incompliance th;SanJoagyin County:Ordinance Noc:549 for sewage or.Na.,i•1862 for well/liurhp,and tl1e,.Rul€fs and iiegulations:of the,San-Joaqu n
<br /> Local Health District t ,. , ,+ s t h + �?i`^ ^SYY .3 ;C c t'�jC r'is
<br /> '".s, -s '; 3..�'1a;1}a � .�. ,.�C.C} 4., ,I. :$�`_ s r:}. �; �. -4 t
<br /> p� ;t' ;.'�:` rf't !" ,I i + ��; F S" #"� r;: �ti 1 E'==',.�'` "ttr'�i!� i•4p�S4� 1�€'la'0 TC.� rli r{f .1� ,� .'.�-
<br /> Job Address ` City) Lot Sizer � �M;
<br /> tee. 4
<br /> _ JUN t`
<br /> Owner's Name . Address %/A - Phone
<br /> E ..... ,....
<br /> Cont`ractor's Name,- License No. 4 Phone'
<br /> TYPE OF WEL UMP NEW WELL® WELL REPLACEMENT ❑ DESTRUCTION El
<br /> i r PUMP'NSTALLATIOWIE SYSTEM'REPAIR 13OTHER ❑` i
<br /> ANCE TO,NEAREST: SEPTIC TANK_ ! SEWER LINES ! + - DISPOSAL FLD. PROP. LINE ;
<br /> € DIST
<br /> FOUNDATION AGRICULTURE WELL 1 OTMER-WELL PITS/SUMPS
<br /> A—
<br /> i INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 r }
<br /> i
<br /> - ;❑ Industrial - ;-- - ❑ Open;Bottom. ; - Manteca Dia.-of Well Excavation. Dia.-of Well Casing
<br /> ' Q Domestic/Private I ❑ Gravel Pack E .0 Tracy Type of Casing Specifications
<br /> ,, ... ❑ Putrlic . fl Other ❑ Delta Depth of Grout Seal € Type•of Grout
<br /> Irrigation • lpprox.;Depth ❑ Eastern z Surface Sea! Installed by
<br /> L Repair Work Done I ry Type of Pump H.P. State Work Done r `
<br /> 4
<br /> r Well:Destruction ❑ Well Diameter Sealing Material itop 50i.
<br /> _.., Depth Filler Material A Below 501. r
<br /> TYPE
<br /> ! OF SEPTIC WORK: NEW INSTALLATION E3 REPAIR/ADDITION DESTRUCTION ❑ 1 N septic stem permitted if public sewer is.
<br /> _available within 20feet.)
<br /> v r
<br /> F Installation will serve: Residence___-Commercial_ Other y 9 _ 1 _,
<br /> kJt
<br /> _ .. c
<br /> Ndmber of living units: Number of bedrooms
<br /> Character of soil to-a-depth of 3 feet: Water table depth
<br /> F SEPTIC TANKS i❑ �TypelMf9 Capacity No. Compartments - ;
<br /> r. , ; .
<br /> PKG'TREATMENT PLT.:❑ ; Method of Disposal
<br /> :Distance to nearest:+"-- -Well -�Foundation T Property-Lin ,
<br /> �r 1
<br /> ..
<br /> i
<br /> LEACHINGRDLINE �^„� Distance totnearesteS Well F # Foundation + Total length/size Y
<br /> F1LTE E g , Property Line
<br /> SEEPAGE PITS ❑ ]Depth Size l Number, r s
<br /> I ._.s —
<br /> E -SUMPS-t-- Distance to'nearest.•”" ' -Well � " "'F"`-FoundationProperty Line -s• `' I ^° '�"�' ' •�
<br /> i
<br /> 'DISPOSAL PONDS{ '❑ ! F # A. Z l
<br /> `•I hereby certify,that'l have prepared this application and that the work will be done in accordance with San Joaquin c'ourity ordinances, state'laws, and,
<br /> • --'rules;and'regulations of the San Joaquin Local Health bistnct
<br /> } `Home owner or licensed 'agent's signature certifies the fallowing. 'l certify that in:the performance of the work for which this permit is issued, I shdll not
<br /> ,----employ
<br /> any person in such manner 6s subject-to workman's compensation Iowa of,California."Contractor's hiring oulsub-contracting signature
<br /> certifies the following:"I certify that in the performance of the work for which thispermit is issued I shall employ persons subject to workman's compensa,
<br /> r.-. .. .. 4.
<br /> _._...
<br /> tion laws of California."
<br /> i ±The applicant muat,all for all required inspections. Complete drawing on reverse side: f
<br /> E Title• at i
<br /> Signed0: oV
<br /> Date:
<br /> 5-a
<br /> • t i i � b � s :: _.._�..FUR DEPARTMENT ONLY
<br /> . r - Date re t
<br /> Application Accepted y �..� Area
<br /> !pit or Grout Inspection by Date Final Inspeon tip' T Date
<br /> ctii
<br /> jMclitional Comments L`UUl` u
<br /> ,_. O.Stk-, 466-6781-s---0Lod,-"36-3GL1 Manteca{ 623-7104 ---s-_O-Tracy ...5-6385
<br /> �Applicanti- Return ell copies to: Environmental Heakh Permtt/Services 1601 E. Hazelton Ave. P 0 Box 2009 'Stk.,.CA 95201: [ _
<br /> AMOUNT DUE AMOUNT.REMITTED V" e RECElVEQ 8Y _ �" aAIE J m
<br /> + i' i I P,EfiMiT NOJ
<br /> ',,FEEi
<br /> t { I INFO, € _ Ham+ { 1 }
<br /> + EH 1324{HEV 10/831 Ca l.,5- '!� S? h ��1�D f �^'Y ( "^.�EH 14-28 / _ i 1
<br />
|