Laserfiche WebLink
rl <br /> t <br /> t <br /> _ APPLICATION FOR PERMIT <br /> - SAN JOAf1UIN LOCAL HEALTH DISTRICT <br /> .601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466'6781 <br /> rt7 PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) cation is <br /> mado to the San Joaquin Local Health District for a permit m construct and/or install he work here{n daxdbad.This eppR ,f <br /> Tx Appllcatbn is ha:eby q <br /> t <br /> made m con ulmnce wi0:ilio Joaquin Count;Ordinance No.SE9 for sewage or No.10621or well/pump and the Rules end Regulations of the Sen <br /> Joaquin <br /> h Luca: Health District. <br /> p rte.; PM <br /> T /+.qr�p _ ��a.-•-�lCitY. lot Sixa <br /> Jeb Add•e� O�- f r r r Phone el <br /> 0 d <br /> Ow.gr'S Name _Af <br /> PMS <br /> Address _Licence No. <br /> 'ENT ❑ DESTRUCTION ID WWELL ❑ WELL AEPLACOTIIFR ❑LlPUFEPAIR ❑TYPE DF GFLMTION C SYS <br /> TEM <br /> PUMP INSTAL� <br /> - - <br /> PROP. LINE __- <br /> SEWER LINES DISPOSAL FLD.— <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL_ <br /> =-- PITS/SUMPS= <br /> FOUNDA.Oft! _AGFICULTURE WELL - - - <br /> INTENDED U_SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIDNS Cie.o1 wallCasing '._ <br /> �— -__ <br /> ❑Duan Bottom Cl Manteca Dia. of Well Excavabpn.- SwiRuticns <br /> ❑IndusLial„ Type of Casing__---- <br /> D Domestic/P:ivatn ❑ Grave!Peck ❑Tracy Depth of Grout Sea! _ Type of Grout__ <br /> Il Other fl Delta <br /> t" Public Surface foal Installed by <br /> I I Irnpstior. _Apnrox Depth I I Eastern _ State Work Done <br /> `r H.P.__ :.. <br /> Repair Work pone U TypWell of Pump Sealing Material(top So'I _ <br /> ,y Wall Denruchorr O Well Diameter <br /> Final Maleral(Below 50'1 <br /> Depth ----- tic system Mrmtried it public sawar is •• <br /> available within 200 feet.) <br /> ` TYPE OF CEP RC WORK: NEW IIJSTALLA TION RLPAIRI ADDITION DESTRUCTION I i INo sap <br /> Other_ <br /> butallation wiz serve: Rasidenee_ Commercial <br /> Number of be - Watar b depth J- <br /> Number et 4r:ng unity: dr t.b <br /> _ -- <br /> . Character 01 dorl to a depth of 3 fact: L'eDdeity------- No'CorrDartmsntt <br /> SEPTIC TANK O Tin,•:/Mfg - Mothod of LisPosel <br /> PKG.TREATh'FNT PLT.❑ Foundat;on Property UM1° <br /> Distance to nearer Weii_�_-- . <br /> Total is <br /> j LEACHING LINE <br /> N. <br /> 4 Ler.0th of lines _--�- - 1 1- pr try Llrte <br /> Foundation-_ <br /> FILTER BED ❑ Distarce to oriental: Niel_129 ---_ <br /> �.. Number ' .7 <br /> a, ' _ 1 I Depth <br /> Sue Property Line - <br /> SEEPAGE PITS Foundatior._ <br /> SUMP <br /> IT Distance to nearosr Wel'_DISPOSAL <br /> i� <br /> DISPOSAL PONDS r, Sao. i __ nate Nwa <br /> � od this application and that the work w+ll be dono.n acco:dance with San Joaquin county ordiMnces, �Q.�s <br /> 1 M,abv certify that I heve prspat 1"I not <br /> odes and rogolatirms al the San Joaquin Lowl Heel[h District. f which this Permit b issued, : + <br /> ,. i <br /> Home owner 0,licerrvod agent's signature car dies the 11tim I certify that is the t-A of once of Rte work w <br /> employ any Y•*sm:'n such manner as•o beeline subject to workmen's comoenaation laws of Cd.l.,ie."$onty pt filling d ob'�kn ' c ngper�w <br /> eerUtras t y p lsor,in "1 coYily mat in the performance <br /> of the work for whlen this permit is iav»d,I sial)amptey peso lecT <br /> tion"lewc of California." teta <br /> g 1' <br /> ' The aPdicant <br /> Title: /un tsl�r all requiretl Ina i!ons.Complete drawing on tetania side. - f1�! �^ One: - p1 - <br /> `yam-3!{C,, <br /> Signed i 4 <br /> FOR DEPARTMENT USE ONLY / -z <br /> Date -s 3Arae <br /> gpgliutbn Arcepted EV Data L5/1..is3 <br /> Date _ Firel laspectfon by ✓ r .�yy <br /> Pit or Grout Inspection by -- 1 <br /> Addilki-I Commeatr <br /> s• 'r � 'Memece J-7700 <br /> h.,GA 9521 <br /> ❑Stk 466.6701 O Lod! 369-WI th Pa�ndt/Services 1601 E. Hidellon qw.. P.O.Box 209.S <br /> nmente!Has' <br /> Applicant Return all copies to: Envire �S <br /> r <br /> -- -x RECF.r(ED BY DATE PERFAD,NO. <br /> 2 FEE AMOUN?OUE AMOUt!T REMITTED SASH I <br /> INFO i , <br /> '` ..EN uta IRW'vnu <br /> EM r Ili <br /> � f <br /> a� <br />