Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �^ <br /> Telephone 1209) 468-8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> fCornplete in Triplicate) <br /> Application is hereby made to the Sen Joaquin Local Health District for a permit to construct and/,,, the work looks deacr6ed.This app6eaaon is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 far well/pump and the Rules and ReglYllorr of ore Sea Jnwfuln <br /> Local Health District. /,l r7 j A <br /> Job Address _ i SZ 7.r✓. E• I1z T/ Ems ' CRY 4 / M00 �Lsott Sim to �G PM <br /> Owner's Name P,r leC LAIf', 1p�ddi.r 311 W 6ft&/ e' .V 20 Phone 394 - <br /> Contractor It Address 75/87 6,04 4:32ALicense No. 3q!SyZPhom 4' 130 <br /> TYPE OF WELL/PUMP: NEW WEL0K WELL REPLACEMENT C DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 'Lt�^ <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES DISPOSAL FLD./A9• PROP. LINE JAQ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO <br /> C Industrial 'Open Bottom ❑ Manteca Dia.of Was Excavation Dis.of Wall Cawtg <br /> Domestic/Private f i Gravel Pad ❑Tracy Type of dWw41 SpadB nj" <br /> C Public i 1 Other ❑ Delta Depth of Grout Seal A Tyle of Grout <br /> C Irrigation 'L b Pprox. Depth ❑ Eastern Surface Sall Installed by <br /> Repair Work Done Type of Pump H.P. State Work Dore <br /> Well Destruc'ion C Well Distretm Sealing Material(top 50) <br /> Depth e.PRJ— Fiber Material(Below 60') <br /> TYPE OF SEPTIC YORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION L] (No septic LynamP;:ttad B Public saws is <br /> avexebis withkt 200 feat.) <br /> Installation will e�Reaidencs— Commercial_ Other <br /> NumLar of living units: ��I r Of bodmoms <br /> Character of so'1 death f 3 rat• Water lobe dsDih <br /> SEPTIC TANK Typs/Mfg C nv No. Compertrrents <br /> PKG. TREATMENT PLT. i- Method of Dispose <br /> Distance to morwt: Well FouRr ion A Line <br /> LEACHING LINE No. 6 Length of Imes Total length/era <br /> FILTER BED Distance to notion: Wall Foundation Property Lire <br /> SEEPAGE PITS Depth Sire Number <br /> SUMPS "- Distance to more Wall Foundation Prop"Una <br /> DISPOSAL PONDS L <br /> I hereby certify that I have prepared this application and that the work wM be done In accordance with San Josquln county ordinances, nae laws, aha <br /> ruin and regulations of the Sen Joaqulm Local Health District. <br /> Home owner or licensed agent's spnsture oertBles the fosowing: "I certify that in the performance o1 IM work far which this permit is Issued, I MM rpt <br /> employ any parson in such manner as to become subject to workman's compensation Iowa of CdBornis"Cononctor's hiring or sub-contracting signets" <br /> canities the following: "I certiry,that in the Performance of the work far which this Pemmt is Issmed,i slur employ persons subject to workman's compnea� <br /> ton laws of California." <br /> The applicant m c 'for all requbed 4pecton em drawing on reverse sine. p <br /> Signal X_ ..C_ _ w���LiTiIN: �7/Lf�. Dan: �7d <br /> / FOR DEPARTMENT USE ONLY a� <br /> ApdicaGnn Accepted by I/�� Date j/ Sys AIN <br /> Pit Grout Inspection by �'—T!'�`U Dan - ��-` FNal Inspection by w9 ' 7LLl. 6o:.— Dan <br /> Additional Comments _ - <br /> C. Sok 4666781 Lodi 301-3621 ❑ Moo n 823.7104 ❑Tracy 835-SM <br /> Applicant Return all copies to: Environmental Health Pemat/ServiNa 1801 E. HaaMton Ave., P.O. Sm 7009, Stk., LA 86201 <br /> FEE AMOUNT DUE AMOUNT REMITTED U9H RECEIVED BY DATE IERMIT'NO. <br /> INFO I I E <br /> . lee wars sry - UU CA'1 0•lv� (•��b I ?- <br /> Ea mt 7a <br />