Laserfiche WebLink
J <br /> APPLICATION FOR PERMIT <br /> SAN JOAGUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete in Triplicate) <br /> Application is hereby made to the San Joaqufn Local Heakh District for a permit to corwruct and/or install the work herein+descrfbed.This applii a ion is <br /> made In compliance with San JoKuin County Ordinance No.688 tot sewage or No.1W2 for well/pump and the Ruffs and Reguistitxts of the San Joaquin <br /> Local Health District. > C} <br /> Job Aodrtass ___RC1 3� r rA ._i '_. city 7,t Lot Size PM ` <br /> if <br /> r <br /> Owner's Nerve �t1_\t-rcrt, Address '+°" Phone <br /> contractor ` dress t�- f[r�+ "st No,. C�5-1781hone <br /> TYPE OF WELL/PUMP: NEW WELL Chi WELL REPLACEMENT 0 DESTRUCTION 0 <br /> PUMP INSTALLATION C, SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWEff LINES ___ DISPOSAL FLD.,, PROP.-LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_,PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 industrial l Open Bottom (�1 Manteca Dia. of Well Excavation /' Dia.of Well Casing <br /> Domestic..Private I.::1 Gravel Pack L2 Tracy Typ#of Casing____ - Specifications <br /> Public f­: Other [ Delta Depth of Grout SOW y t' k Type of Grout- <br /> Irrigation <br /> rout-Irrigation ____Approx. Depth © Eastern Surface Seal Instaliied by� <br /> Repair Work'Done D11 T t • <br /> Type of Pump _..., H.P.. __ State W__ <br /> orkDone <br /> Well Destruction o Well Diameters <br /> Sealing Materlbl tttsp Sig"} <br /> S �" ` W <br /> � <br /> Depth '� Fillet f+MStOrial{Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION Ci (No'Aeptic system parmittdd.it public sewer is <br /> k t;,,) . available within 300 feet.)! <br /> Installation will serve! Residence Co� cral� Other - 1 » <br /> Number of Wn units: _._ Number of bedrooms WJ t <br /> 8 <br /> Character of soil to a depth of 3 feat _ �,r� Water-table depth , <br /> 'SEPTIC TANK C✓�SyiMfg . Capacrty_N2. No. Compartments <br /> PKG. TREATMENT PLT..-E Method of Dlsposai <br /> Distance to nearest: WON 01a. Foifndstion_14� _ Property Line_ Y2 <br /> _...._.... _.. _ __I _— <br /> LEACHING LINE No. & Length of fines Total length/size.... ��µ t <br /> FILTER BED L:1 Distance to nearest; Wen._.._v Foundation _ Prop"Line I t?' <br /> f <br /> ._....__ ._......... _ _..... t <br /> SEEPAGE PITS C Depth l Number_....._ <br /> SUMPS G Distance to nearest: WW Foundation Property Line <br /> DISPOSAL PONDS,, ; l r <br /> I hereby certify that I Dave prepared this application and that the work will be done in accordanca with San Joaquin county ordinances, state laws, and <br /> rules and ragulationi ofi the San Joaquin Loral Health District. <br /> Home owner or IicansWd amt's signature certifies the folloiwing:'"I certify that in the performance of the work for which this permit is issued, I shall not l <br /> employ any person in such manner as to become subject to workman's compensation laws of CaNcimia."conUactor's hiring or sub-contracting signature <br /> certifies the following;3 I certify that in the performance of the work for which this permit-is issued,I shall employ persons subject to workman's cornpensa- <br /> :ion lanae of Cailfornia..' <br /> The applicant m n f r all required` pert+ons. Complete drawing on r side. <br /> Signed X ''� ; ��L.?rl�tlx> r Title: Date: - <br /> y R 44£PAfi"TlUIENT 115E rDtIfLY <br /> Application Accepted Eby Date \ ( CZE Area _— <br /> Pit or Grout Inspection by Date Final inspection by AL1 \' Dat <br /> Additional Comments:,a5'�� 4-.-r " '�r—�.� C_ s>`--' <br /> C Stk 466-Ml i CI Lodi 3W3621 C;Merrttnca t3-7108 L]i Tracy MS-63% <br /> Applicant- Return all copies to:Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O, Box 20b9, Stk., CA 9=1 � <br /> FEE I AMOUNT DUE , AMOUNT REMITTED R RECEIVED By DATE PEAMrT`NO. } <br /> INFO r 1 <br /> - ' 1 <br /> . tai 19.24MEV., <br /> EH 14-20 <br /> _ <br /> . a <br /> w,' <br />