Laserfiche WebLink
i, APPLICATION FOR PERU IT <br /> SAN JOAQUI14 LOCAL HEALTH :IiSTRICT <br /> r. <br /> l tool E. HAZELTON AYE., STOCK FON, CA <br /> .. . Tuieptfate (2M)400-Ml ",A <br /> PERMIT EXPIRE&VYEAR'FROM C.%TE ISSUED <br /> (Complete in TrlpLeste) <br /> l Ap;ikstlor's hereby nude to the SPn Josgrdn Local Health District for a permit to ccov ,end/or Inuts4 the work herr daanrlBslli•T7dx as�Yasl"wr b <br /> mI In ourr,pik tog with San Joaqukm County Oreirurxa No.5"for suwol,a No.1862 <br /> for�:ztl/p.rvrp Md the"W"era?Ragraatkrr of tfu Esc JotWl+n <br /> . Lam:Mishit OiMrict.. <br /> �.ry. -y r /.c ___ _ �S.A�OV Iw S'¢e �, PM <br /> 9Cy,, uvne,'s Nero nr/V_ <br /> C ¢-- <br /> rmttec*, er Address—_ t— __License Na _ Phone <br /> ' -TYPE OF WELL/PUMP: - Ny�'y WELL ❑ WELL REPLACEMENT f' > DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ___ SEWER LINES - DISPOSAL FLU.— PROP."LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLi9/ <br /> _PfSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ <br /> .rdustrlal C Upset Bunom ❑ Manteca Die.of Well Excavatinn —_. Diu.of Well CMIV <br /> C Domettk/Private ❑ G,"Peck ❑Tracy Type of CWng__ .—_—_. SpecNrc sdors <br /> PubI ❑ Other ❑ Delta Depth of Grout Seel Type of Gmvt___._.__._—____ <br /> f <br /> Irrigation --Approx. Depth ❑ Eastern Surface Seel Installed by _ <br /> zI Work Dau ❑ Type of Pump H.P. _ State Work Done <br /> Wan Destruction. ❑ Well Dienater __ Sealing Material(top W) <br /> Depth Filler Material f"OW Ffi <br /> 50')TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LJ DESTRUCTION ❑ (No septic system Pal"~B pudic Nawar is .� <br /> available within 200 ho0.1,:... - <br /> h <br /> Installation Will serve: Roxidence_2C Commercial_ Other <br /> Number of Irving unitar_ Number of bedrooms yL Z <br /> Character of loll toe depth of 3 feet: _Sgllfj[.. r /w�(v.�r.. __Water bbl,beth <br /> SEPTIC TANK QY Type/Mfg ,� -f^N R//! Capacey_ /4-C 0 No. Compartments -7— <br /> PKG. <br /> LPKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest Well Foundation. Property Line <br /> LEACHING LINE IB' No. 6 Length of linos rO i Total leoTh/aha_ <br /> FILTER BED ❑ Dis!ince to nas all: Well Founclarti.:KII Property Llost <br /> s SEEPAGE PITS C Depth _1Q.� Size_� � Number <br /> SUMPS ❑ Distance to nearest: well. _ Foundation_!ate Property Line_-L2,LY'— <br /> DISPO'.:AL PONDS ❑ oT yDs <br /> 1 hereby certify that I have Prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state lava,and <br /> roles and regulations of the San Joaquin Local Health District. <br /> Home <br /> Home owner or licensed agent's signal.,,certifies the following: "I cattily that;othe performance of the work for'whicfi this pet is aud,I Stull not <br /> employ any person in such manner as to become subject to workman's compensation laws of Califon"."Contractor's hiring or sub-contracting signature <br /> candies the foloWng:"I certify that in the performance of the work for Which thyyermit is issued,,I shall employ parsons subject to wc,krrvm's comperaa. <br /> tion la•.s of California." / <br /> The applicant»mum call for all requ"�ad inspec' ro. Cgmpiete dewing on reverse side. <br /> Signed%_S,Q' s6/�J Title: O'W1wt/ _ pDo e: <br /> �`� Date <br /> FOR UEPA TMENT USE ONLY -- <br /> Application Accepted by Area_ _ /ys_ <br /> Pit o,Gro.:Inspection by Data__Z Final Inspection by <br /> Additional Comments: <br /> iJ Stk 46&6781 ❑ Lodi 3(i3621 antaca 8237104 _,Tracy 8356388 <br /> Applicant-Rstum all copes to: Environnwntel eaith Permit/Services 1601 E. E azelton Ave., P.O. Box 2009. Stk.;CA 96201 , <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE -PERM N0. <br /> INF'] , ��� �/ <br /> '9-7 <br /> "' Ea ma25 <br />