Laserfiche WebLink
DATE <br />7-2-3 <br />APPLICATION FOR PERMIT <br />PAN JOAQUIN LOCAL HEALTH DL. R. <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is heieby made to the San Joaquin Local Health District for a permit 10 construct and/or install the work herein described. This application is <br />made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1062 for well/pump anti the Rules anti Reputations of lhu San Joaquin Local Health District. <br />Date 5/3-B Application Accepted by Z3 Area <br />FOlikATMENT USE ONLY <br />Scaling Material Roo 501 <br />Filler Material (Below 50') <br />PM 0/7 Z.7.G Lot Size Job Address <br />No. 2--/75Y2 Phone <br />/ Owner &.7 's Name - 7 <br />Contractor 7-7/47///,./c'f <br />3‘ <br />•••11, C:4 '25- -7 "2 License <br />%'S27 Phone&Z974:E-'Z <br />Address <br />Address 671,e <br />INTENDED USE <br />0 Industrial <br />ri Domestic/ Private <br />11 Public <br />I Irrigation <br />Repair Work Done <br />Well Destruction <br />07 <br />H.P <br />Dia. of Well Casing <br />Type of Casing .."....c...,./,- Specifications <br />Depth of Grout Seal,.//6--/ 7 2.0 Type of Grout <br />Surface Seal Installed by .,,,,,4`t•-;,,:s -47;-",,,,”.- <br /> State Work Done <br />Dia. of Well Excavation 4-.; - <br />PUMP INSTALLATION n <br />DISTANCE TO NEAREST: SEPTIC TANK <br />TYPE OF WELL/PUMP: NEW WELL 0 <br /> <br />WELL REPLACEMENT LI DESTRUCTION U <br /> <br />SYSTEM REPAIR 0 OTHER" 5-c-/Z -"- <br />SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION II DESTRUCTION i I INo ptic system permitted if public sower is <br />available withip 200 feet.) <br />SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br /> Date <br />Installation will serve: Residence Commercial Other <br />Number of living units: Number of benroorns <br />Character of soil to a depth of 3 feet: Water table depth <br />LJ Type of Pump <br />0 Well Diameter <br />Depth ?L- <br />TYPE OF WELL <br />la-Open Bottom <br />0 Gravel Pack <br />0 Other <br />26.APPrOs. Depth <br />PROBLEM AREA <br />0 Manteca <br />11 Tracy <br />Delta <br />I I Eastern <br />CONSTRUCTION SPECIFICATIONS <br />C Stk 466-67131 0 Lodi 369.3621 0 Manteca 623•7104 0 Tracy 835-6385 <br />Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br />AMOUNT DUE AMOUNT REMITTED RECEIVED eV PERMIT NO. <br />Pit or Grout Inspection by Dino Final Inspection by <br />Additional Comments: <br />1762/w <br />Cx <br />CASH <br />FEE <br />INFO <br />. ElI 13-24 (REV, I/ <br />1F4 14.20