Laserfiche WebLink
;4 tis,.wr APPLICATION FOR PERMIT r„�( <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> v 1601 E. HAZELTON AVE, STOCKTON, CA <br /> R' <br /> Telephone (209)466-6781 <br /> Z' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to the San Joagon Local Health OWnct for a pem*A to Constrict and/or install the work fw"Gh dwc►ib►d•�TTW Sen APPRceft-s le <br /> made in oompliwocs with San Joaquin County Ordinance No.543 for sewage or No.1862(or wall/pump and the Ruleule the <br /> Rus and Regtiorha <br /> Local Health District. 0 <br /> Job Address . O D r `"• R—'" `} I city V� Lot Site ; <br /> Owner's Name <br /> w �A�s.7 Address Phone . <br /> 1 � r• <br /> Cormactora Named OELL Llcer„e No. t+ s� php+e f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT u DESTRUCTION Tff y <br /> PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK ___SEINER LINES DISPOSAL FLO PROP.LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> MENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O lndusvw ❑Open Bottom ❑Moo.teta Die.of Well Exvtvston Die.of Wil Casing ; <br /> D Domestic/Private O Gravel Ps* 0 Tracy Type of Casing Speciff edo"s ?� <br /> O Public O Other O Deka Depth of Grout Seal Type art .74 <br /> ' - <br /> G Irrigation _-Approx.Depth O Easton Surface Seel Installed by <br /> Repair Work Done O Type of Pump H.P. State W Donal <br /> Well Destruction ❑ well Sealing Material(top W) <br /> L-;- btw Filler Material(Below W1 1 �/ Y <br /> -.t <br /> TYPE OF OF WORK: NEW INSTALLATION CJ REPAIR/ADDITION O DESTRUCTION O (No septic systamPsnmkted if public 9V~Is <br /> avadabfe within200 feet.) <br /> T <br /> Inetaliation will serve: Rasidence— Cortxr+erciai_ Other <br /> Number of living unlit Number of bedrooms :Aa <br /> Character of sod to a depth of 3 feet Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity no. <br /> convertrnefft <br /> PKG.TREATMENT PLT.O Method of Dbposel ` <br /> 134anee to nearest: Well Foundation Property Lire <br /> LEACHING UNE ❑ No.b Length of tines Total length/ <br /> FILTER BED ❑ Distance to nearest: Wed Foundation Property Lina <br /> SEEPAGE PITS O Depth Size Number <br /> SUMPS ❑ Distance to neersat: Wen Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby oertfy that 1 have prepared this approcaticn and that the work will be done in accordance with San Josqufn county ordinances,ant@ laws,and ` <br /> rubs and regulstiors of the San Josgt.'Irh Local Health District. <br /> Home owner or licensed agent's signature cvb iso the foiowkg:'T certify that in to performance of the work for wAhieh this permit is issued,1 she not ) <br /> �* employ any person In rich manner as to bacons subject to workman's compensation laws of CeWornle."Contractola hiring Or ribtontractng signature 3 <br /> art{,Kthe klowing:'9 certify that in the performance of the work for which this pemhlt is leased,I shall employ parsons subject to workman's col Oleo - <br /> tfon laws <br /> The ust all or nequ speed .Complete drawkq on neverse side. c c <br /> Signed <br /> Title: cab: �d <br /> D ENT USE ONLY <br /> o 0. 7 O <br /> Application Accepted Dab / Ane ;t <br /> Pk or Grout knee nim by Om Raaf Inspection by Dib <br /> ud Aewdon sl Comments. <br /> ❑Stk 4911-Ml ❑Lodi 3W-3821 O Manta 823-7104 ❑Tracy 83645M <br /> Applicant-Ream d copies to:EnAronmenbl Health PwmWSwvim 1001 E.Hazelton Ave.,P.O.Box 2008,Sit.,CA 86201 <br /> f DUE AlMOUffT IIEIhtfTTED CJ►SH <br /> RECEIVED BY DATE ►ElphrT NO. <br /> W <br /> r <br />