Laserfiche WebLink
APPLICATION FOR PERMIT <br />' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hodehy made t0 the San Joaquin Local Health District for a permit to construct andror install the work haver-(described.This <br /> made in comph rote with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wen/pump and the Rules and Regulanons of the <br /> Local Heal!! strict. )�� <br /> Job Address , �..J' I —f L>!`_l.�C1 _ City U I r•-vt2c:_ Lot Site - ---- PI1 <br /> 1 <br /> Owner's Nam., �,:c;,tj _Z(t t f;aL4LAtidreas•t�� y! r�-1 t• Phone JXL( <br /> Crmtrectrt 1,. :, L IislYr n�_(G Address /.I C F, t !G. —License No,S rS•� It P irk J E';t <br /> TYPE OF WELL PUMP: NFW WELL WELL REPLACEMENT i 1 DESTRUCTION / <br /> PUMP INSTALLATION SYSTEM REPAIR H OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK _-- - SEWER LINES DISPOSAL FLD. —_- PROP NE <br /> FOUNDATION_ AGRICULTURE WELL OTHER WELL PITS: 'nPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industr.al I :Open Bottom i 1 Manteca Die of Well Excavation_____ Dia.of car . Casing <br /> Gomesp• I'ri�nU• I Gravel Pack Tracy Type of Casing._ --__ Specifications <br /> Public L]Other (! Data Depth of Grout Seel Type of G—ut _ <br /> Irhgahnm _-Appros. Depth Eastern Surface Seal Installers by <br /> a j Repair Wmn 11om,• Type of Pump H P. _ — Stall Werk Dona <br /> d' :•_i`, Well Destndc non WON Diameter _ Sealing Material(top 50'1 -- <br /> Depth Filler Material 1Below 501 <br /> TYPE OF tit PTIC WORK: NPW INSTALLATION IREPfM ADDITION r DESTRUCTION I ' (No septic system prrm • n public s <br /> available within 200 Ifart <br /> Installalmn will%eive: Residence '' COmmwrcral Othet <br /> Numtw•r of twrmq units: - /.- Number of tTrdrooms J-_� <br /> Charas ter <t •.ud to a depth o!J Not ... .(j C-1—jr-!a__c r.. Water table dMit, <br /> SEPTIC tnNh. 1 1 T"w,Mfq Capacity No Compartmerrts <br /> PKG TREA14x1NT PIT I Method of Ds(xna+ <br /> Drstatdce to nwarMt Well _ _ Foundation Propenv I nor! <br /> LEACHING I IN( Nn. A Length of tones - , — Total le"thtso" :)o_� Y•Jl <br /> FILTER WD Distance to nearest WeN r <br /> :S_4'_., FOuftdalbrt�C __�. lkoperty Lrrte _'S-- _--- <br /> SEEPAGE Pl f•, P Depth <br /> SUMPS 1' Distance to rtearwst: WON /('L�_ Foundation le'- Property line 611' <br /> DISPOSAL PONDS <br /> I hereby c#,,i,N that 1 have preparerrl thrs application and that the wo,,k will tAf done in accordance with San Joaquin county Ord-+mace,stat <br /> rules and tiqu'm-ons of the San .Joaquin Local HNhh District. <br /> Home nwrw•r.w Ircens•M agent's signature candies the ludlovvmp -I certify that in the performance of the work for which this p•••nrt N issuer <br /> employ arty persmn in such manner as to become subject to workman's compensation laws of CAkfomra-Contractor's Mang or s-it,contractiT <br /> ceftdres the fo'rmw•ng "I certify that on the pwrformance of the work for which this pwrrrwt is issued.1 shall employ period»tNlApct to workman'! <br /> tion laws of (;0 0"fl,•t•• <br /> The appPca-! .%t •ail for all requeer)inspection Complete draw ng on reverse side <br /> S c rn•d1 K 1` k- t <br /> I <br /> rtlA ` Datil j•• r• _ <br /> FOR 11PARTMENT USE ONLY L ! <br /> to .. Data i � • An,y �„� / <br /> f'a w G.•... -,6 bl'_ 74. <br /> •u+ Lodi X9 U21 Mantes 11121.7104 Tracy MS43% <br /> nl,hi,..•! .r� npres to EnvironPteetat Heath Permit/Services 1001 E. Natation Ave., P O Roe4 M Stk CA 95201 <br /> K It <br /> I AMOUNT DUE AMOUNT REMITTEO CAS.f RECEIVED fay DATE of uyyf NO <br /> f•.•t:. r. C • vat C -- — %I4 --- <br />