Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1801 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 46"781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompWte in Triplicate) <br /> AppEcw.on r Imob y ode ro Ifr San Jotglwl Local"MOM District Nor•01 - tg Cor RnXt aM/a mtN the woh hare+,devatil". This si-pdkadon a <br /> Waft w cwlpwry with SahJoatprin Counh Ordnance No.5"fol sewage o1 No. IM2 to,w,,I end the Rules end Reg,"hona of the S In Joerluirl <br /> Local Health Do"ct <br /> Jtlb A alum, Z L7 lot Sin iA'r��TO� PM <br /> owwa Na1//na�� I `== 'i+�.�-- Addess __-_ Pierer -TINM L/ <br /> Cetdtachm'! a- '!" --••-/sJ Address _Llctme No.20—"L PMna <br /> TYPE OF WFLL/PUMP: NEW WELL O WELL REPLACEMENT 11 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK // SEWER LINES DISPOSAL FLO._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PRS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Atdlratrial ❑Op.Bottom O McWte Dia.d WN Fets.ation Diu. of WN Casing _ <br /> Domntc/Prvsh 0 Gievel Pace C]Tiler- Type of Caaalg 'o^a <br /> I'!Public: f 1 Other Il Dote Dap:h d Grout Seat Type of Grow <br /> i t Yrq.xwn _Approv. DePta I 1 Eeaten1 Sudan S"lmtaaed by - <br /> Raoaa Wod Derr rw Type of P,mp -- H. State Work Done- - <br /> Wag DeHructon I] Well Dianna, Seating Material flop 50.1 -- <br /> Depth _ Filler Material(Below 50') - - <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No semen syVlere Permitted d Put*c saver r <br /> f iwail"within 200 1411 <br /> IrutNeran vie serve: Residence X- Commerclel— Other <br /> Nunder of"Www _ NumMr of <br /> CharacM of sate so a M.Mh M 0 fah: �+ w Water table depth <br /> SEPTIC TANK 4 Type/Mfg No. CO"w �m <br /> PKG. TREATMENT PLT.I] Method of <br /> Disposal <br /> Dieraltea to mallet: WN A )/F f2_- F GPM , Late—a D d <br /> LEACHING LINE A No. A LenpWm i otN length/pbe <br /> HInl d <br /> FILTER BED L I Distance to rteeraaC WN Foundation1 PFoPerIII I Its— <br /> SEE! PITS I I __—_Sin <br /> SUMPS tartc tp neral: WN Founda ^rlfrersY - <br /> DISPOSAL PONDS I I <br /> I Meby candy that I twee prepared tno appl'cxmn errd that the work Will be der m accwosnee wish San Joaputn count)'wdmancee. state teres, ald <br /> rules and 11"I err of IM San Joa9uat t'cal 1lsalm Om""— <br /> Homme owner m lcomw again a erwurun certdre the folowklg: "I certify that n tfr pwfownrice of the work for which this permit Is iasueJ,1"not <br /> ItI <br /> edea the Foao+wV 1 tamely 1M, I h,pedermer¢e of tM wore Im h,h this tpe~is "W1, ahM erCn 10,perwn euolechkiV w W wwktma"ccgnu'�. <br /> tan teal of Csmmr <br /> The appacant,twat W 1m N r '-Is0 rmWr'. Complete drawing m revery W>.. G=!9 < - <br /> S'wr.d X_� - _. TnN: �GY-TKA —__-_ __.-.— Data: <br /> ( _/ >7 <br /> _ 4 _ <br /> FOR DEPARTMENT USE ONLY <br /> Appbu/t°J.'yAccccclpNd try Data ,2 /-� - A. p <br /> Pe d OFaDt 1n Date 0� Fine)Inepctron by y- - 3-�/ `Oat�_�L. <br /> A ddeipnel Cernnrnr: <br /> Sd 4CA 6791 C Lodi 9899621 C ma W-1104 C Tracy 83S SM <br /> Appkcan, strut"N COPra to: Emrkomtrmal Health Pat lrlit/Services tSDt E. Hazslm Ave.. P O. Boa 2009. Gtk., CA 95201 <br /> i[f AMIDL'[ AMOLMT AFaI7TE0 �.A aFCf nrtD av DATE <br /> N[O -- <br /> EI- lil;_1 <br />