|
' APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT
<br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA
<br /> a i.. Telephone (209) 466-6781 t, �✓ I� a N
<br /> PERMIT EXPIRES TYEAR FROM DATE IS
<br /> Sl1ED
<br /> « (Complete 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 d.►acrlbed,Thts applleatlen is t
<br /> made in compliance with San Joaquin County Ordinance,``o.549 for sewage or No. 1862 for well/yump and the Rules and Reg,datlans of the SaAJot lAs.'tw'
<br /> Local Health District.
<br /> Job Address _ City tot Slze j " r PM ' }
<br /> # Owner's Name � AQdress Phone
<br /> F ,Conlfactor ltA 1 JI+ 7k Address License No„ Q, Pho 4
<br /> s -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION p
<br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑
<br /> 7
<br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE .r'
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSr°= p ° *
<br /> `!INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONStl
<br /> a Industrial �ti 0 Open Bottom El Manteca " Dia.of Well Excavation Dia of Well Casmg �"�'�� ��•;�"
<br /> ❑Domestic/Private ❑Gravel Pack 0 Tracy Type of Casing Specifications
<br /> ,t 1`9.Public { f7 Other fl Delta Depth of Grout Seat Type of Grout { .
<br /> '1 1 I ri{lation qhs -Approx. Depth I I Eastern Surface Seal Installed by
<br /> t d`Repair Work Done j G Type of Pump H.P. State Work.Done '' P•'•
<br /> Wei 1 Destruction '-I[7 .We11 Diameter r r"� Sealing Material(top 56'1'' 1trw t5 w"4Nl�'a'F t?.i"1r
<br /> r r w { '
<br /> iii . -n roes
<br /> Depth Filler Malarial(Below 501
<br /> 4L:'-.TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR ADDITION)q DESTRUCTION I I INo septic System permitted rl pubkc'sewer is'
<br /> available within 200 feet.)' *1�
<br /> instatlation'will serve: Residence_ Commercial Other
<br /> x it 4 ,rr ti�
<br /> 3 Number of living units: Number ai bedrooms 4 / k a, }
<br /> r Character cf 9:4 10 18 depth of 3 feet: 1 Water owe'
<br /> , ❑„ Type/Mfg 1 Capacity_ No.Compartments
<br /> < r11
<br /> PKG.'.TRFATMENT PLT.❑ , Met hnrt of Disposal, "' 1 �
<br /> } '•" Distance to nearest Well Foundation e.Property Lute al 6 Taw;r'>«
<br /> `ve
<br /> LEACHING LINE ,: + ❑ No:Q Length of lines_x Total length/size k f ` -�
<br /> FILTER BE , p Distance to riearoat: ' Weit Foundation Property Line" t" ' � s f` ,
<br /> t s .
<br /> Cv r
<br /> SEEPAGE PITS�Ir , it <Depth
<br /> Size' Nu�ber ,s ' i s
<br /> SUMPS' t .Distance to nearest: Well
<br /> Foundation�� Property Line S
<br /> A J..DISPOSAL POND.) } ❑ t s;g. '/ ° t .
<br /> 1 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 regulatkxm of the Sen Joaquin local Health p3trict. „Ye xa1
<br /> +� Home owner or Iken4d agent•a signature certifies the following:"1 certify that In the performance of the work for which this pemtlt is ittta,l shall not t,,�
<br /> ,.employ any person in`such manner as to become subject to workman's-cdmpensation laws of California."Contractors hiring or sub-contracting sigrlaturo ;}�•
<br /> 4certifies the following 1 Certify that in the performance of the work for:which this,permit Is issued,I shall employ persons subject tti workman's compansa-t-1-
<br /> 1..,w <,60A laws of Cwdci t�✓r: 7 e" k �we fi
<br /> The* 64
<br /> apglicari tl f fired n t 's. drawing on reverse sista. °•
<br /> 4u ac n a
<br /> dtSigned ' a Title:} ���- Date-'
<br /> ate
<br /> `.'f .} «,. .• _.y f FOR DEPARTMENT USF_ NLY ry %
<br /> � a _
<br /> t r :Apdiewion Accepted t1y 1. _ Area
<br /> C1ate
<br /> Pit or Grout Inspection by `� f_ Date/ Final Inspection by 1 prtt r
<br /> Ao.TKlonal Comments: / Y' �• -i 't irk "e
<br /> O StkN46B-8781' ' Lodi't 369.3621 Q Manteca 823-71 Q Tracy,,.83cr6385 s Ut►`°�"�i M�� k W4Y �iF
<br /> Applicant tl geturn all copies to Erwironmental Heahh Permit/Services 1WI E. Hazelton Ave P.O.Box 2009,Stk.,�9rr20T
<br /> 4 t � s +Ck br q�.»`K�,4�1,. A _Ir ,�� o t < ;y.: .. syr,.,.,' S'.._,a. e.'. :. ♦ d
<br /> IN
<br /> AMOUNT DUE AMOUNT REMITTED CASH' .:RECEIVED BY PERMIT NO, "
<br /> �+�, ,. F t � �" rK+u+saibe�,,� w ::r•{�st{�*t�, "i:p"� .,
<br /> s
<br />
|