Laserfiche WebLink
's APPLICAT110N FOR P��N�fiII <br /> ' SAN ,JOAQUIN LOCAL HEALTH D9STINCT <br /> '1601 E. HAZE(T ON AVE., STt3C KTON, CA <br /> Telephone (209) 466-6761 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ,)2-5— <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 n <br /> ty Ord'oeiance No.549 for sewage or No.'1862 lot well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Coun <br /> ' Local Health District, O <br /> City L®t Sire <br /> Job Address S s <br /> CM American services 505 Cal7TIL4]@itY 1AnP- Ujr-0fii 211(1 Ems., J50J'5 Phone <br /> Owner's Name Address <br /> df 1 n Address License No.-- Phone <br /> ' ontracY <br /> NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION Q <br /> TYPE OF WELL/PUMP: <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER)( <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE . <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia.of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of CasingSpecifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy PuType a of Grout <br /> M Public ❑ Other n Delta Depth of Grout Seal <br /> I I PuIrribation —..Approx. Depth I I Easter Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r --°°----��--- <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top 501 <br /> Depth <br /> Attc`4�C�9111eP'Ilt <br /> Depth 5t Filler Material (Below 501 t� <br /> TYPE OF SEPTIC WORK: NEW INSTA,LLAlIUN I REPAIR/ADDITION I 1 DESTRUCTION 1 1 a�vailseptic system <br /> ithin m0 er�eitted,il public sewer us <br /> ' commercial— Other li <br /> installation will e: Residence <br /> Number of living units. Number of bedr000ns <br /> ' Character of soil to a depth feet: ter table depth <br /> Cirno t <br /> SEPTIC TANK ❑ Type/M Capacity No. crments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: oundation Property Line <br /> ' LEACHING LINE ® No. t Length of lines Total lengthtsize <br /> FILTER BED ❑ Distance to.. st: Well Foundation Property Line <br /> SEEPAGE PITS Iii` epth Size — Number � <br /> SUMPS 0 Distance to nearest: Well Foundation Properelt LRIe - <br /> ' DISPOSAL PONDS ❑ -- .-- ---- <br /> I - <br /> 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 /> hat in the performance of the work for which this permit is issued, G shall not <br /> Home owner or 9censed agent's signature certifies the following: "'1 certify t <br /> employ any parson in such rnannar as to become subject to workman's compensation laws of California."'Contractor's hiring or subcontracting signature <br /> certifies th ing: "I certify th performance of the work for which this permit is issued,I shall employ persons subject to workman's eompensa- <br /> ' tion la of Calif o ia." / <br /> The a licant mus celef r J II E®ganlrecl it actions. Complete drawing on reverse side. <br /> Signed X Title: Permit Agent Date: Sept- 28 1989 t ; <br /> FOR DEPART6MENT USE 01MLY <br /> ®ata —. Ar®a - -- <br /> �ppiiratioruecepted by �J <br /> --- <br /> Pit or Grout Inspection by l <br /> Dale Final inspection h�J ,1-_.__ Date ✓'' <br /> f3eturro all copies to: Environmental Health Manteca <br /> 1823-710 1604 E. Trac on Ave., P.D. Bou 2009, SYIt>, CA 95?f99 <br /> Additional Comments: -.e---- <br /> © Stk 966-5789 ❑Lodi X69-3629 ❑ fuAantece 823-7404 ❑Trace 835-6385 <br /> ' Applicant <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> lea FEE �ivli(?UNT DEPS AMOUNT REMITTED CASH <br /> 4 X71 ° urdF® o <br /> °nlfo) � <br /> 43S A � �$ <br /> FH 14.20 =m — <br />