Laserfiche WebLink
L 1 z, <br /> `�` APPLICATION FOR PERMIT : <br /> SAN .IOAaUIN LOCM. HEALTH DISTRICT <br /> Ifi01 E ;HAZE:,TON A1/ :aSCiC4TON, <br /> ' 15 <br /> Lt'�i <br /> h0-dr- <br /> ;, �'rERMIT EXPIRES 1 Y>+ARbATL� 1SSt ED `mak , F a i,k t � r '. <br /> ,:. III _ f1C�lp��t�,lf� FfL4t��z i'�+k dx:-crd < <br /> '4 f •}j d.. m76' t q.' x it t-v` <br /> ' Application tri helsby mage to:the Safi Jo eith � � y <br /> made in compliance with San Joaquin County Ordinance No�549 f .tsewe N8 1862 fgtjrgelf/pump and the Ru'lar�i v the 8 Irt <br /> y V y;a ,. c -r r r" x a t z:F'v1r a kyr?�1��4T� ,.•1§'a Ts i rx41"� ' <br /> =:;Local Health Distract. j �P '�S '„ <br /> `1 r � t ,a ,,i. f -xC4 5�r rR,��yJry f,rp��!r - <br /> // 54 tx Ls r t d 7 3 ° * ear s" <br /> !.. :� C/'- rrr���"•€ ; :t ; �c 'Y ,�, z R+, rr�F`;4'_z �Yj,�` �'x 'T`' f-,' <br /> Job AddressEl <br /> '` Ci lfiot izea . r <br /> `411T"'I'v <br /> _ f....' - \ Y�,'~,'F„U •1ry`£ F a �' H�,Lf� s ,SSS j `.Y.d y�`-� <br /> � <br /> .b�Y ''' / `�/• s x, ! s F f7 s .�1- �` lahOrla 1y•r <br /> DVwter�a Name <br /> ' <br /> I ;: License"N6."Contra01 ess . y Phone <br /> E1Ri' <br /> E OF WELL'/PUMP: klfEEf� v ��i. WELL REPLACEMENT' <br /> li s it i,.. i ..�. 7. G�y•n� : r •"'�� _- > •..y '�) <br /> t " PUMP IN�TALLTION ❑ SYSTEM REP <br /> / DISTANCE TO NEAREST :SEPTIA _q' DISPOSAL FLD w ^,;PROf' INt; <br /> _ =5iFOUNDA'#'IOiJs ;. . : AGRIC E WELL: OTHER WELL, '',PITS/SUMPS, <br /> 1NT DED USE - ', `OF Wf`LL t r R AREA CONSTRUCTION=.SPECIFICi4TfON$ <br /> y w:- x .a eP S3�tro r$ arA b :k ri <br /> ' 'C]}Industnal fO Qpen Bottom Manteca + , Ola:•of Well Excavation f I}ia BII Casing <br /> Ff a. i i .. i s w. r- ='- e +?:, -1 ;-.w. A:; --. S _-;��, -x� .,� .� ,+. r �I v r -, r q _ <br /> " �E <br /> f r3lborrlesnc/Prorate3 Gravei Pa -� ;Tracy > x Type of,Cesing �����{{+ 1 G <br /> ,. y -r S4-�y'4. -' T-,s Y �3*. f <br /> bs'G`rol�i <br /> nti r �"�` fl.Delta + oe <br /> � p': t � .,+.; � 'u.. .Ta,• at.,M.�. '# a-+i,wca S •!•�r st" N- �; <br /> Y:- <br /> g�tl Frrg two pprox:Depth i i 1:IEastem it 4 Surface Seal Installed byr i �e "` <br /> Repai.'WOrk Done z❑ "'fype'o Pomp y xn ryW a# Cfs�_ :x r _ tate 1�i�r)rl(jDW1a <br /> �,i..g <br /> V. <br /> t �iif 1.i;}gatrucsion� C�" Weil Dla "ter" SeaCmg�Materlal lto 5fr�7 t�° �� <br /> rx. A y}•Vi`'72 777777777, <br /> Depth } Iler;N�aterial <br /> c" p TYPE OF SEPTIC WORK NEW INSTALtA'TiON f 3 YR IRYADDtTION i I pE RUCTION 1No septic spermitted If publid sewer Is <br /> F `" �rt�� \ ; r .#► s, actable w+ I 200 feet.} <br /> Installation -¢-.- <br /> wilt serve: Residence Commercial tFier } i <br /> Number of livin ' nits. Number of bedrooms,. <br /> Character ofs 11 to depth•of 3leet r or table depth j <br /> r <br /> SEPTIC TANK ❑ Type/ ` Cape No.'Compartmenta <br /> PKG. TREA. EN LT ❑J, Method of Disposal <br /> F <br /> Distance to nearest: Well F tion Property,Line <br /> LEACHING IN No. of nes Total length/size <br /> FtL 'B to a to nea t: Well Foundation Property,'Line <br /> SEEPAGE PITS i B Depth Size Number <br /> SUMPS T; q.Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C] J <br /> I hereby certify that I have prepared this application-and Arthe work will be done in accordance with San:Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies.the.follcwing: "I:pertify.that in the performance of the work for which this permit is issued, I shall not . <br /> employ any person in such;manner as to become subject to workmari:s compensation laws of California."Contractors hiring'or sub-contracting signature a <br /> certifies the following:'9.certify that in the performance of the work for.which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California," _ . <br /> The 00cant t call jor all r uireeQ-Ar^fs . Coompl to drawing on rev side_ 7j � 1 <br /> Signed X "� �� /I,_ .�G title: � - i Date: <br /> „�3A<ATlNUSE ONLYr r ;` <br /> Application Accepted by ` -.D Area t <br /> a <br /> Pit or Grout Inspection by Data Final Inspection by - Date <br /> a <br /> Additional Comments <br /> R FC},-Stk 466-fj78f r{� 0 Lodi 3 3G2t " ❑ Ma_rltecs=.s8?3 71644 0 T►acy ;835-6385 <br /> 2- Applicant Returns-all=i�ples to Errvltonrtterttal:Health Psrmit/Services 160f E Hazelton Ave, P.O, Box YON,',Stk.;,;CA 66201 H <br /> FEE OUNT DUE,- /1MgUrIT REMITTED gECEIV PERMIT'NO p <br /> tAlFO. V'CA <br /> x . <br /> ♦ EH 1,•�I IRt11 Iln61 a _ , rsn,. s •=,,`tet p ,,� t ,,. _r �J! ii- <br /> }4'x �EH 1E•7a ,"'ate ak�K'�'r't --:.... r� X�' �?7 '-.rorA a ,�•-..,:��'-w ., � .;• !{ X�??�� F � r -; <br /> :�:. .4.. -. :�- ::��s-L :� a�s Y 3s . :y. ,a"•s'c•rr. • ..tr � ,�.-,csr:.Y r. . �y - ,,� <br />