Laserfiche WebLink
A-0 <br /> APPLICATION FOR PERMIT <br /> SAN JOAaUIN LOCAL HEALTH tDiSTRICT <br /> 1607 E. H,AZELTON AVE., STOCKTON, CA <br /> Telephone {209) 4664M1 <br /> `PERMIT EXPIRES YEAR FROM DATE ISSUED <br /> (Compiets In Triplicate) " <br /> f APPli ion is hereby made to the San Joaquin Local Health District for a permit to construct and/or instIM the work herein described..Tapplication s <br /> made in compliance with Sen Joaquin County Ordinance No.549 for sewegN <br /> s or o.1862 for weN/pumP and the Rules and RepW*m of theme � <br /> Local Health District. r%. I , <br /> ��-�C _ <br /> t� City " Lot Sita�2.�, PM <br /> Job Address <br /> Phone <br /> Owner's Name PA7iPi/G !/ Address ,«_.�...�� .w.. . .. . <br /> ' 7ce7rse-NnLs'Y�L _Phone <br /> contractor Address loY1 S' A!• <br /> l TYPE OF WELL/PUMP: �} NEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION D <br /> KjUMP tNSTALLATION'O SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEARI=_S'C:.MPTIC TANK '� -SEWER LINES DISPOSAL FLD, PROP. LINE <br /> %FOUNDATION / AGRICULTURE WELL — OTHER- OTHER WELL PITS/SUMPS — <br /> ' INTENDED USE TYPE OF WELT L PROBLEM AREA CONSTRUCTION SPECIFICATIONS01a.of won <br /> Caskig <br /> 13 Industrial f d Open Bottom- (5 Manteca Pis.of WON Excavation <br /> .l3 Domestic/Private D Gravel Pack ❑Tracy Type of Cam Specifications <br /> I 0 Public VIE)Other ,._❑..Deka. _ Depth of Grout Seal Type of Grout <br /> [3 Irrigation `1 __Approx. Depth ❑ Eastatn.. Surface Seal Installed 1]y <br /> Repair WorkD'one ❑ Type of PUMP H.P. State Work Doha <br /> Weil Dest.A'n © yVelltDiameter� Seating Material(top e<f•j <br /> Depth Filler Material(Below 50') y <br /> is <br /> PE OF SEPTIC WORK. NEW INSTALLATION ©=REPAiR/ADQlT10N DESTRUCTION ❑ (gNvaoilabN within P if public sewer <br /> ,Ilw6lstion will serve: Resldance' Comnrerbial Other <br /> ec=r <br /> flunits:�i umber of bedroomsuf il.to a6depth of-3 feet: Wa[a��t�abia daptft <br /> rlta �' <br /> SEPTIC TANK Trype%Mf¢—�P •/A-.-- —Cape Plo. 4ornpa <br /> r <br /> PKG.TREATMENT PLT.❑ A Method of Disposal <br /> Ofstana�mjnearest: Well Foundation PapeRYLine <br /> / — � Total lerigthlsae �f � � <br /> LEACHING LINE 'No. &'Length of lines i J <br /> j , FILTERED ❑ Distance to nearest: Well Foundation ' Property Line L - <br /> ' .ji&AGE PITS er'Depth _gS' t Size 3S., Number <br /> y� . O' Property Line /m <br /> �UMP$ ❑ Disfen `n�'re§f: l'fCe11„�., °d ' Foundation . <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I hove preparad this application and that the work vrNl be done in accordance with San Joaquin county ordinances,state laws,and <br /> rules and ragulations of the San Joaquin Local Heakh District. <br /> liortra owner or licensed agents signature certifiesthe following."1 certify that in the performance of the work for whkch this permit is issued.I ahaI not <br /> employ any parson in such"*niter ae to Become Ub_J6ct to workman's compensation laws of Califon-da.' <br /> Cot>itactor's hiru►g or sub-contracting signature <br /> certifies the fosowing:"I certify that in the performance of the work for which this permit is issued.I shall empty persons subject to workman's componse- <br /> tion taws of Caffomka.1. <br /> The applicant must calf for all required Inspect ons. Camplete drawing on reverse side.. <br /> Signed Title: <br /> A F4R EPARTMIEl11T USE ONLY r1 1 p <br /> ApPNcation Accepted by Data -Are, <br /> Grout Inepeotion by htapecdon by_ { <br /> Additional Comments: <br /> ❑Stk 40SZM3 ❑ Lodi 368.3631 ❑ Manteca =-7304 ❑Tracy 835.831 <br /> Applicant-Returnall copies to: Environmental Health Permit/SerAce$-S601 E. He¢akon Ave.. P.O. Box 20g8, Stk., CA 2Q1 <br /> RECEIVED 8Y DATE PERMIT`. <br /> GK <br /> )NFO AMOUNT()UE AMOUNT REMITTED CASK • <br /> oe <br /> +rat 13-24 IRkY.i/Bal . r hot <br /> EM 142* ��♦ a '... <br />