|
APPLICATION LFOR PERMIT
<br />SAN JOAQUIN LOCAL HEALTH DISTRICT
<br />1601 E..1-1AZELTON AVE., STOCKTON, CA
<br />
<br />TelePt-t rie (209)466-6761 ,
<br />PERMIT EXPIRES 1,YEAR FROM DATE ISSUED
<br />;; 4a<(Complete ,in Triplicate)..
<br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thii.application is
<br />made in compliance with San Joaquin County Ordinance No 549 for sewage or No. 18E2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. a eNit,e',“": 10 • • 4 .4(..,f3 k3. ;t'
<br />Job Address -
<br />-
<br />City -
<br />0
<br />........ .-:., :. :..:17'.,...; .- CI ,F51,2: re Ow
<br />;„
<br />s Pho Owners -Na me , / ... ' if • i.:',...-i ' Adds _ ne41Z
<br />-' - • ' - . _., ,, _ . _
<br />Contractor'S Name -le- License No. ' 1 7 +4- t Phone 36c"if33
<br />TYPE OF WELL/PUMP: , NEW WELL 0 WELL REPLACEMENT EJ DESTRUCTION 0
<br />PUMP INSTALLATION 0 : ' ' SYSTEM REPAIR 0 . ' OTHER L '
<br />,DISTANCE TO NEAREST: SEPTIC TANK ___L SEWER LINES DISPOSAL FLD. PROP. LINE
<br />: FOUNDATION AGRICULTURE WELL ___ OTHER WELL. PITS/SUMPS _
<br />, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRuCTiON SPECIFICATIONS ' l
<br />5 Industrial - Ci Open bottprn 0 Manteca Dia, of Well Excavation . ‘ Dia. of Well Casing
<br />El DomestIc/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications : 11 PI:Ibl,c . b Other: . U Delta' . Depth of Grout Seal Type of Grout . ,
<br />Li Irrigation __Approx.•flepth 0 Eastern , ..,, • Surface Seal Inetalleti by i
<br />Repair Work Done I-7 Type of Pump H.P.1....,' . I State Work Done .
<br />Well Destruction 0 'i Well Die'rneter Sealing Meteriel,l.top 50') . , 3 Depth • - 'filler Material (Eielocy"501 " --
<br />TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ge DESTRUCTION 0 (No sePrio system Permitted if Public sewer , .
<br />c4s f' available within 200 feet),
<br />Installation will serve! Residence Commercial ther
<br />is
<br />_....."'
<br />`-
<br />,
<br />. 1.1 ir . 0 y Number of living units • L---- Number o1..: ',co ma ----- I./ ' , ;di•
<br />Character of sail to a depth of 3 feet: - t / a A.- " La . Water table depth :
<br />SEPTIC TANK r E A • Type%Mfg I I Capacity -,,, No. Compartments .
<br />PKG. TREATMENT•PLT. C I "As, 1 a Method of Disposal 4 ' •• . Distance to nearest: Well Foundation 1 ' - Property Line
<br />. r'' /2..., , , 7 I , .,,.. LEACHING LINE E.:"......No. & Lengtn of lines -70 *, "‘ -f i f ' Total ksngth/slz 40 .
<br />FILTER BED i- - 0 Distance to nearest:..3, Well .1710 "L>felr.L.—Foundation" .2-0 ' Property Line
<br />/..5 ----T .1 a I. I*, tj. ;ire-- -•'-`71 zo .
<br />SEEPAGE PITS Size .34 - .,•••• -,..../1 ,'• 'tiiiurnber--- Z2-:
<br />SUMPS • 4- ....- -.'01 Dista1
<br />nce to nearest: - Well /0 0 ' " Foundat'ion: Property Line,' 06 ._.21:11'' ,
<br />DISPOSAL PONDS (I , ! •",:. 4., „,,,..,*:„..:, i a.,___„,„, - .:,
<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. -1-------;---a, --L...-.. ---
<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
<br />f. 'employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring Of sub-contracting signature
<br />!c•rtifies the ft:Wowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject toworkman's compensa-
<br />Ilion laws of California." f .
<br />i .
<br />i.Signed X Title: 15(.0%.,--.•
<br />, .. ,
<br />I: p
<br />
<br />
<br />' ,
<br />. Date ,...,` _c- La 'efi / :Apricadon Accepted by
<br />'91Date.2:nr _ Final Inspection by . 2.---e-P''''17,7,6 -y7;4'‘dDate 2;1'. S'-‘5'
<br />.
<br />. .-.
<br />°/
<br />• 0. . . o.
<br />1.0 Stk ' 486-6?91 -4. C Lodi - 3139-3 .- iTi 621 -,. Manteca 823-7104 .0 Tricy -,835-85 83 4+ ), _ . . - •
<br />Applicant - Return all copies to: Environmental Health PermitiSetvices 1801 E Hazelton Ave., P.0 Box 2009 Stir CA 96201
<br />„
<br />,
<br />;
<br />`...; •_•ft.
<br />t
<br />
<br />•
<br />
<br />PM
<br />-
<br />of
<br />d'--04',),)' The applicant Must call uired inspections. Complete drawing on reverse side. •
<br />DEPARTMENT USE ONLY
<br />Grout Inspection by
<br />t •
<br />EH 1344 titer. um. ; 011445
<br />•
<br />eiE- ;INFO 'AMOUNT DUE 't • 7 ''' AMOUNT RENirrfE0 ' ' CR, * ''' , cAs8 4 - — '. RECEIVEO SY . . . ,
<br />DATE. P0tMIT NO.
<br />. ',.
<br />. . . i 1 - - . ''''''
<br />"Additional Comments: f ' • ,
<br />%
|