Laserfiche WebLink
U <br /> APPLICATION FOR PERMIT ��� I-t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4l+.nC S 1601 E. HAZELTON AVE., STOCKTON, CA UUU <br /> rrf? Telephone 12091,486 sial JUN 1987 <br /> C R PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENViROMENTAL HEALTH <br /> L1T TM1tVECES <br /> Application n hereby made is the San Joaquin Lout Hastth District fa a poir"d to construct amtor instill the work harain descr T s application is <br /> made in compliance with Srn Joaquin County Ordinance No.519 for sewags or No.18611a wootpumppppand the Auks and Regutations of the San Joaquin <br /> Local}(eallh District. 1 D� �yj p�C OA 1,.`V4--A) <br /> Job Addrets fyQ"""`� _ CityiR2 ' '` I.oe_Sizer PM — <br /> {r� rr X307 Md"-C4't Phone bf��7Z -SZ 00 <br /> " Owner'■Name. Address <br /> Contraclor E ' .1 1"A(e Address `�'+�1 5 License No. Phony /5 �S <br /> TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO­ PROP.LINE <br /> FOUNDATION ____ AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Mon�fi�ri UJrt,��5 <br /> 0 Industrial ❑Open Bottom ❑Manteca L;a.of Wall Excavation Cie,of Zfl Casing <br /> ons <br /> O DorresticlPrivate Q Gravel Pack 0 Tracy Type of Casing � � L _ SpKificairrou � <br /> 1'1 Public ['.1 Other n Delta Depth,of Grout Seal Type of Grout <br /> I I IrriDalion __Approx.Depth [1 Eastern Surface Seal installed by� <br /> Repair Work Done 0 Type of Pump H.P. ____- State Wo,k Done_ <br /> Wel:Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth File Material tBetow 571 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIRIADOITION I I OESTRVCTtON 1 11ND septic system permitted it public sewer 6 <br /> available within 200(ast.) <br /> Willaffalion vein serve: Residence_— Commercial— Other <br /> Nun-bar of living units:_ Number of bedrooms <br /> Character of too to a depth of 3 feet: Water tabla depth <br /> - SEPTIC TANK O Type/Mfg Capacity No.Compartments <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to Poorest: Woo Foundation Property Line <br /> LEACHING LINE Ll No.6 Length of lines Total tengthlsiza <br /> FILTER BED ❑ Distance to nearest. Weft Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 1.1 Distance to nearest: Well Foundation_ Property Line <br /> DISPOSAL PONOS Il <br /> "-' I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state taws,and <br /> rules and regulations of the San Joaquu%Local Health District. <br /> - Home owner as licensed agent's signature certifies the folfawing:'9 certify that in the perfarmance of the work for which this permit is imied.I shall not <br /> Emptoy any person in such manner as to become subject to workman's compensation laws of California."Conlrattols hiring or subcontracting signature <br /> cartiliea the following:'7 certify that in the podormance of the work lot which this poernil is issued,t shall amploY persons subject to workman's compansa- <br /> tion taws of California." <br /> The appricant�maustt Gag lot.air teau'liredi�nsspeec�t�ions.Complete drawing on reverse side. ,(_ / C <br /> Signed X 1 4'1 �/sLL,,+ "".� 'IM 0-, Title: Y'. `,L'�-1 r4% Date: Z--7� <br /> IF d <br /> Y ht Il Tri V1 (4'V--t—FO EPARTMENT USE ONLY {G <br /> Application Accepted by <br /> Dara <br /> < Date Final Ins tion b Date <br /> t. Pit or Grout Inspection by `f V� Y <br /> Additional Cammentc . <br /> ❑Sik 4566781 D Lodi 3643611 ❑Manteca 923.7104 ❑Tracy 835.5385 <br /> '- Applicant-Return all Copies to: Environmental Health Permit/Services 1601 E.Hezalton Ave., P.O.Box 2009,Stk.,CA 95201 <br /> FEE AMgUNi DUE AMOUNT REMIT"fED K H AECEIVEO BY DATE PERMIT'NO• <br /> IN <br /> W.fir 11N Irl[V.I r.ar thle <br />