Laserfiche WebLink
APPLICATION FOR PERMIT j <br /> SAN JOAQUIN,LOCAL.HEALTH DISTRICT t <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA i <br /> Telephone 12091 466-6781 l <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Comp in.Tri licatel <br /> ISSUED- <br /> (Complete <br /> ,. 'a� _,r� �e a':E �:�F ��tr i 'F.=��t,.t,�.•��, ,� P ° <br /> ` Application Is hereby//lade to the San Joaquin Local Health District for a permit to construct and/or install the work hsvaln'derctibed.This is i <br /> ,,,made in-cornpkrtce,whhiSon,Josquin�Cwnty-Ordinance No 549 feesewage or No..1862 for well/pump and Nie Rules and Repufadorn of the Sari Joaquin <br /> Local Health.D . <br /> ' <br /> Job Address City. Lot SiZa - f PM. <br /> owners NarT;ar>?T>�C-i4iid Address D Q»C `MiK�1 __`Phone <br /> Contr15 . Z •Phone� ­2 Life <br /> ± <br /> TYPE OF WELL/PUMP: NEW-WELL 0 WELL AEPLACEkIENT, ❑•. 'DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑. SYSTEM F PAIR 0 , '._ ;OTHER 1co1n 'QX6 eACL <br /> F, L <br /> DISTANCE TO NEAREST:;SEPTIC TANK. ` ,SEWER LINES,,_4 �;DISPOSAL FLP. �.PROP. LINE <br /> ` FOUNDATION ' AGRICULTUfE'WELL OTHER WELL PITS/SUMPS I <br /> NTENDED USE-, TYPE OF WELL' PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> t. <br /> .11ndUstrI4I_M, P_Ar#0A*tiAP-. Ops -66 tihi ~�'o-Men '" D of-Wep Eiccav�ti n ` Die. of Wall Cm" <br /> Dor�1P ©'GnWal Pads L,- ❑ T � * `� ype of Cast��^iloAry��` SPeciRcaUo <br /> ❑ Public ❑ Ott ,. ❑ De w Depth of Grout�Seal L Type of Grout <br /> b,lerigier►;s ' ' `=q�jtproit Depth_.. Q Eastern ~�a t Surfer Seal lnstaileQ by .;6204 Assw-ikes, <br /> x <br /> :? Repalr Work Done �•.Q Type of Pump . H-P,. ": State Work•DorW: <br /> T .. <br /> 'Well Dsamc ion ❑ Well Diameter ' Material (top 60') <br /> --.-.-- - Depth °,Filler Materiel(Below 50') j <br /> TYPE OF SEPTIC W NEW INSTALLATION a. ,FIEPAIR/ADDITION ❑:,QE�ST8UCII�JDN RANo aep0c- permitted if public sewer is <br /> a. .} _.,.. - availa&W in 200 feet.) <br /> Installation will serve: R nce Commercial_ .Other <br /> �,- Number of living units: mber of bedrooms <br /> Character of sob depth <br /> to a of 3`feet. "_' Water 1. depth <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: I Foundation roperty Line <br /> LEACHING LINE ❑ No. 8 Length of linea T I length/ <br /> FILTER BED ❑ Distance to nearest: Well Fou Property Line <br /> SEEPAGE PITS ❑ Depth Size ber <br /> SUMPS ❑ Distance to nearest: Well Foundation perry Line <br /> DISPOSAL PONDS 0 <br /> I 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, I shall not I <br /> employ any person In such manner as to become subject to workman's compensation laws of California."Contractoes hiring or sub-contracting signature 1 <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 /> The applicant must call for all required inspections.Complete drawing side. <br /> �J A GAUSS" ITS-KJ�' V-.�86 <br /> Signed Title: Date: <br /> A USE ONLY <br /> Application Accepted by Date A <br /> Pit or Grout In Date Final Inspection ,//:ZIf <br /> Additional Comments: — <br /> ❑ Stk 4868781 ❑ Lodi 3e8-3821 ❑ Manteca 823-7104 ❑Tracy <br /> Applicant- Return all coples to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 . <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO �1C/�A,SH <br /> r EH 1324IREV r/asl as .3S 0 V V 1� M D <br /> man <br />