|
APPLI.CAaTION,;FOR-.:-
<br /> PE R M IT
<br /> nt
<br /> SAN JOAQUIN:LOC4! EALTH
<br /> DISTRACT",
<br /> 1601 E. HAZELTON:AVE,, STOCKTON, CA
<br /> �� f .
<br /> r Telephone20 - 678'1
<br /> f 9}. 466
<br /> PERMIT EXPIRES�7 YEAR FRP0,15ATE,IS $UEDQ
<br /> rs
<br /> Application is hereby made to the San Joaquin Local Health District fora T i E � rrF�V b e[�NVfR ' s1 NTA-L-HEALTH
<br /> jt�1�' Y
<br /> _ made incompliance with San Joaquin.County Ordinance No 549,for sewage or No';7862 for well/pump and the,Rules and Regulations,of the San Joaquin r
<br /> permit to construct and/or install the work hereir`1}f�&j6V, I��
<br /> Local Health District. r� ��e
<br /> r r f? ys# -
<br /> E ') 4 O tC7 s>
<br /> Job Ad o t �
<br />! dress {/� s.=Y�a 't 11'':,^t3�?''9 Z}rflt rfo bll£f ,"f.+ t=,,
<br /> •� r ; e ls:i`.SLiJr'J {✓-,�..> -f, 2✓1'
<br /> ` City ;LOt Size{
<br /> Owner's Name . PM: 4
<br /> _-
<br /> Address _
<br /> i on
<br /> 'RPh e•�
<br /> ;. . _.Contractor's Name _ j
<br /> TYPE OF WELL/PUMP: f i' License No `,
<br /> I NEW LL ❑ WELL REPLACEMENT ❑ Phone
<br /> PUMP INSTALLATION'❑ DESTRUCTION ❑
<br /> DISTANCE TO NEAREST;-.SEPTIC TANK S STEM:REPAIR,K H
<br /> Y OTHER [J
<br /> SEWER LINES �
<br /> DISPOSAL FLD. I
<br /> FOUNDATION ^ AGRICULTURETWELL! PROP. LINE
<br /> iNTENDED USEROTHEA WELL' PITS/SUMPS �!
<br /> �PF ndustrial EPR08LEM AREA CONSTR{jC710N SPECIFICATIONS
<br /> ❑ Manteca
<br /> Domestic/Private Dia.-of Well_Excavation i
<br /> ❑ Gravel Pack ❑ Trac I of Weil Casing
<br /> IJ ? A y TYPe'of Casing
<br /> i ❑ Other, ❑ Delta .-_w"" - of
<br /> cations
<br /> 10 Irrigation Depth of Grout,Seal -' =
<br /> ?�Approx.•Depth. ❑ Eastern Surface Seal Installed by.
<br /> .'~ Type of Gtout
<br /> Repair Work Done I Type of Pump l �_ !
<br /> Well Destruction � .� Sealing Material (top
<br /> H.P. State Work Done
<br /> ❑ Well Diameter � ��
<br /> Depth � �^ Filler Material {Below 601
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONi❑ REPAIR/ADDITION ❑ pESTRUCTION Q {No septic'system perm tted if
<br /> p~ ubli wer is
<br /> _ Installation will serve Residence available within 200 feet:► ;,.;
<br /> Commercial., Other '
<br /> Number of living units: Number of bedrooms
<br /> Character of soil to a depth'of 3 feet. r
<br /> i .;. ..�.
<br /> f
<br /> SEPTIC
<br /> ,TANK a❑_. Type/Mfg '' Water table depth k
<br /> PKG.'TREATMENT PLT.i❑ _ Capacity'--�^ No. Com art 41 .P
<br /> v Compart
<br /> * I Method of Disp al '
<br /> Distance to'nearest,
<br /> Welt' Foundation � e p
<br /> roperty Line
<br /> LEACHING LIN
<br /> ' i E ❑ No. & Length of Inas
<br /> 'FI LT
<br /> .4 1 1 Total length/size .k
<br /> +❑ Distance to nearest: We Foundation Prop ��.
<br /> II'`-�� F� datio Li
<br /> SEEPAGE'PITS i erYy
<br /> d=D stance f Size:
<br /> i i r Num
<br /> '_,`SUMPS' .m.._ r ze' r bei;
<br /> to nearest.;, Well: s ,_- FounQation ... « - �..I.•- t '
<br /> £ DISPOSAL PONDS ❑ i �� p
<br /> ro erty Line
<br /> .-rules;and q AA r 1 i
<br /> ! v
<br /> I hereby certify that I have prepared this a Ilcatian and that the work.will be done in`accordance with San Joaquin county ordinances, state laws; and
<br /> regulations of San Joa uiri-Local Health District, • i
<br /> Home owner or licensed agent's signature certifies the foAouvin - i
<br /> -.employ any persor►.in su , 9ra$1 certify that in'the rtormance of the work for which this s
<br /> nner-as to become subject to workman's com permitT1, issued, 1.shall riot
<br /> !certifies the following:" c that in the performance of the work for which��p tion^a laws uCeadli fosharl employ"Contractor's hiring or sub contracting signature
<br /> tion laws of Calffomi ,__.. j , T..._, ersons subject to workman's compensa-
<br /> 'The applicant mus _r F
<br /> -,- r I'req 1 ctions. Complete drawing on reverse s'der I t
<br /> 'Signed r r..may_" :" �,�,,, -� �- _ l
<br /> Title-
<br /> Date:
<br /> Date• ,
<br /> f Ap _
<br /> R DEPARTMIEIVT•USE ONLY I { }
<br /> EA hcation Accepted by,
<br /> a if
<br /> Pit or Greut Inspection by I w �.F ,"� ~ �'' k .i ` -
<br /> T' r. r a�_.... i Date--- Final Inspection by i
<br /> Area
<br /> Additional Comments Date i
<br /> •D-Stk
<br /> 466 6781 • ❑ Lodl, 369-3621- ❑'Manteca'
<br /> " 823 7104 -O Tracy B3r6385
<br /> ,A -.. j
<br /> ppllcant Return all copies to.-Environmental Health Permit/Services 1801 E. Hazelton Ave P.O Box 2009,'Stk., CA 952014
<br /> Y 41.
<br /> u - FEE AMOUNT DUE
<br /> INFO AMOUNT REMITTED OK RECEIVED,BY ;-
<br /> ..r_r ;, 1 CASH DATEf PERMIT'NO�
<br /> EH14.24
<br /> 251REV 10/831 # CASH
<br /> �h-
<br />
|