Laserfiche WebLink
rt M! <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. IIAZELTON AVE., 6DN, CA <br /> Tefaphona"(209) 466-6-6781781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> R (Complete in Triplicate) <br /> i <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 /> 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. <br /> ` �] D <br /> Job Address ( Lp6` , �f` - ' City"; L — Lot Size PM <br /> Owner's Name.. �1 L I F Phi_�--1 jPidd ss 9'-[J��� /1�� �c hoon <br /> �antractor r fry+-`tel/- &r I R-5 AddressAb X� 1JUVLicense No 475�� hon • `��� � <br /> TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> iv d �. PUMP INSTALLATION ❑ SYSTEM EEAIR ❑ OTHfR ❑ j <br /> DISTANCE TO NEAREST: SEPTIC TANK 12 SEWER LINES � DISPOSAL FLD.ML PROP. LINE'�� <br /> FOUNDATION , AGRICULTURE WELL0OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ONS f <br /> V ❑ Industrial Open Bottom ❑ Manteca Dla. of Well Excavation Dia.of Well Casing <br /> `,Zbomestic/Private Gl Gravel Pack-r— 0 Tracy Type of Casin, Specifications, <br /> M-Public- Aft) Other 171 Delta Depth of Grout Seal _ =9W 5a. Type of GroutS�1�! I Irrigation _7(,[�.Approx. Depth l I Eas M Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material(Below 501 -- -- <br /> i TYPE OF SEPTIC-WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> k available within 200 feet/ <br /> r.lnstallatio- rve: Res' enceCommercial = 'Other i <br /> Number,of living units: Number of dro ms � <br /> Character of soil to a depth of 3 fee . Water th V'r <br /> SEPTIC TANK Ar Type/Mfg Capacity o.Compartments <br /> PKG. TREATMENT.PLT.D Method off Disposal <br /> ispo�I lexrh line-e. <br /> - Distance to nearest: Well Fo n Property Line - <br /> LEACHING LINE r' No. &Length of lines Total size <br /> } FILTER BED ❑ Distance' ne Well foundation Propert <br /> r <br /> ! V <br /> SEEPAGE PITS Depth Size -Number <br /> SUMPS 0 Distance to nearest: Well Foundation Ptoperty Line <br /> iWgffOSAL PONDS ❑ <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 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,/shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California,"Contractors 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 /> r The applicant mura. Il for all paired i spections. Complete drawing on reverse side. <br /> Signed X � (`j Title: �-! Date: `97 <br /> FOR DEPARTMENT USE ONLY <br /> • <br /> Application Accepted by Date � 2 <br /> Areaa <br /> /� <br /> Pit or Grout lnspactio Da V Y <br /> Ina!Inspection by /• Dote ` Q <br /> Additional Comments: - <br /> I ❑ Stk 466-6761 ❑ Lodi •369-3621 ❑ Manteca 823-7104 0 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 /> FEE AMOUNT DUE' AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> EH M24 r FtREv. 00 � I <br /> ' f <br /> EM 4 <br />