Laserfiche WebLink
APPLICATION FOR PERMIT <br /> . SAN JOAQUINu LOCAL. HEALTH DISTRICT <br /> 1601 E HAZELTON AVE STOCKTON CA <br /> Telephone 12091 466 6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APplieatton is hereby made to the San Joagiun Local Health District for a permit to construct and/or install the work harem described Mara application is <br /> made in cpmpUanita Wath San JaagUan County Ordinance No 549 for sewage or No 1862 for welllpump and thr Hailes and Regulations of IiM San:oaquin <br /> LOCar Health Distract <br /> Job addraasN rricI" _1 ��ac,fir�Itar �r lj City-- I 4,,C Lot Size.tqC res PM <br /> Owner s Name r t Address C/O `,-te 0-1 Lav 11 T Ivvc1`r ' Phone <br /> h �llI <br /> Contractor !-t ,.ca 7ti«iILr y,Wit-7 Adaress I Ger �n ' License No 4P 7ce-C Pionely! <br /> TYPE OF WELL!PUMP NEW WELL Z tVELL REPLACEMENT U DESTRUCTION V <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Of <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES D'SPOSAL FLO PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLa• ITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ci Industnal ❑Open Bottom u Manteca Die of Wali Excavation Dir of Was Ca" , LheS <br /> Dornestle/PrwateGravel Pack X Tracy Type of Casing____ Speaficahons <br /> Public n Other Cl Delta Depth of Grout Sea! 7 fce 1 Type of Grou.dL— !'k <br /> l r Irrrgat m CZ-j Approx Depth l I Extern $urIWd Seal 1n;tauw by <br /> Repan Work Dona V Type of Pump H P State Werk Done <br /> Well Destruction 0 Wad Diameter -1'rtC,11 Seating Matonai Itop 501 SQIj e-emeri't Q,-D j- _ <br /> Depth SCO Fen!C _ Filler Mstanit 1B*'ow 50.1 <br /> TYPE OF SEPTIC WORK NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION 4-1 iNo septic system permitted d public I;awer is <br /> evadable within 200 feet 1 <br /> instafbtlnn wdl serve Residence. Cormnercuid,.,.. Other <br /> Number of kving urabl Nurnber of bedrooms <br /> Character of sal to a depth of 3 last WOW trb/e depth <br /> SEPTIC TANK ❑ TyporMfg CapWity No Co�npe<aRrorils <br /> PKG TREATMENT PLT ❑ Method of Diapoeel <br /> Distance to neareat Well Foundation Property Lasa <br /> LEACHING LINE CI No A Length of Knee ToW larigith/saw <br /> FILTER BED ❑ Owtwwa to mania Well Foutidatani Propony Line <br /> SEEPAGE PRS it Depth Bis Number <br /> SUMPS Ll Dwane so ne mit: Well Foundation Property Lift <br /> DISPOSAL PONDS 0 <br /> 1 hereby tatnufy thst I heli*prepo,,d ilii* i and that the work wdI be done in eam"riee with San joaquln mu"ord .state Yrwo and <br /> rubs and ragulrborr 00 the Sit Joo*m Lanai/Heath Diiniet <br /> Homo owner or ti wend ap4407%,11 <br /> t colla*dte leilowrrtg I certify that in the pwAormanoa at the work for which itch paa"at R raaumd 1 ahall not <br /> employ+may pormn n owl certdws the WSD%%nq 1 pW hX..= W the work for Much flue paetm el iaaued I*has employ.pertdm gubpm to work�inen a cornparm <br /> tion fives of Caklornmii." <br /> The appkcaMr!I!l x sll �cda+w Cartipbta Arawa+a on r*wrae side <br /> Sag"ad x G` Tide date 3-1- qo <br /> %R D9F%WMEMT USE ONLY <br /> Apabcadw Accepted lair DM Arm <br /> Pit at Grout inmpiwill n by Data Final Ir-go Cdo by pow <br /> AddidmW Cgnbrrart[B <br /> ❑ Still 465-mi ❑ Lodi 389.3=1 ❑Meltmaa 821.7104 ❑Tmv a=4= <br /> 4ppf oftt- Raft"me capros to ErnnronmeriW IParnut/Senncme 1801 E Hen Ave P D Baa 2= Stk.CA SM <br /> ® � AMOUNTOUH AMOUNT RE10iTEd CK 0 <br /> CASH itH�$y®11Y OATH PIPAW Alt) <br /> t►it�aarnev i.waa <br /> Ira f12a <br />