Laserfiche WebLink
//�� APPLICATION FOR PERMIT <br /> Retlise-0 Copy SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (2091466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> AVGicalwn is ttarabY made to the Sen Joaquin Local Health District for a permit to construct and;a instant the wM herein described- Tlth application ie <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welt/pump and the Hubs and Regulations of the San Joaquin <br /> Local Health District. , �( <br /> Job Address . Qts.' 99 7W F-12 __ City_ �r Loi Size .2-*_X.SL��. PM <br /> Owrier'a Name NI 1 X 6 k1Lt1-G1h�•—._— Addreu _2"5�ieo G S�rUlSrr s_�FQE,!/a.sL Phone <br /> Conuicta 2> Woo Address l pf ✓__t_t.o-4-/.f.ELe Lkenu No. �.__Pltone`r'�•ir 9.-?! <br /> TYPE OF WELLIPUMP: NEW WELL O WELL HEPLACEMFNT 0 DESTRUCTION FJ <br /> PUMP INSTALLATION (3 SYSTEM REPAIR'S OTHER C <br /> INSTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> FOUNDATION • AGRICULTURE WELL OTHER WELL PITS/SUMPS _— <br /> INTENDED USE TYPE OF WELL I PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia.of Wall Casing <br /> ❑ iroumial O Open Bottom c ❑Manteca Dia. of Wali Excavation �11B -- <br /> 0 DomesiielPrivaie 1:" Gtavel Padsr Cl Tracy, Type of Casing _ Specifications - <br /> O Public 0 Other.3 t 0 Delta Depth of Grout Seal Type of Grout <br /> Ll Inigation •.--Atgrox. Depth 0 Eaetirn Surface Seal Installed by <br /> Repair Work Dare Type of Pump _ H.P._ _ State Work Done-. <br /> ­ <br /> Well Deumction 0 Well Diameter ______ Sealing Material(tap 50'1 - <br /> •DepthT__- Flow Materiel(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRlADDITION ❑ DESTRUCTION Ll (Noave asystem permitted if PLO=sewr b <br /> e <br /> •/ available <br /> � within 2lJ0 feet. <br /> installation win serve: Residence— Ctrranardal Other _, t <br /> Number of living units: -ZZ- Number of bedrooms..-.— <br /> AJ�y ,�� _ Water table depth— <br /> Character <br /> of aoi to a depth of 3 feet:— ._,.--- ---- 7— <br /> SEPTIC <br /> - <br /> SEPTIC TANK tY Type/Mfg Capaary. /2"c`y __ No, Comtwrtmems -___._._ .. <br /> PKG, TREATMENT PLT. :' Methoa'ol Disposal _ <br /> r <br /> Distance to nearest: Wei,y�D_�Feundabon IO rProperty line,.7` <br /> 9+ . � �' QO r _ glh/siza�"� <br /> LEACHING LINE l.o.8 Length of hoes Total len <br /> - -- <br /> FILTER BED Distance to nearest: WNI -AOWV' Foundation 2-0 --_- Proaerty Line yf <br /> SEEPAGE PRS - Depth Sit¢. Number,..-.__._ <br /> SUMPS, _ Ci Distance to nearest: Woa Foundation - Property Line" <br /> DISPOSAL PONDS O <br /> 1 hereby certify that I have pr",ed this application and that the work wile be done in accordance with San Jeaq:nn county ordinances,state laws, and <br /> rubs and regulations of the San Joaquin Local HeaRh District. <br /> Home owner or licensed agent's signature certifies the tolowing: "I certify that in the performance of the woFrk (or wh cn this permit Is issued. 1 shall not <br /> employ any person in such manner w to become subject to walUrm's armpensation laws of California."Contra.-toes haing or sub-conbac"ll signature <br /> i certifies the fblowirg,•'t cenity that in the perrotmance of the work for which this permit is issued,I shag employ persons subject:o v o'kmen's comp¢nsa <br /> tion laws of must <br /> California." <br /> pE•cant mon --- - <br /> The apwll or all r urredomdete drawing on reverse aide. <br /> Signed x_ = 2 Title: <br /> FOR DEPARTMENT USE ONLY <br /> t(i <br /> gpplication Atc¢ptcd br - <br /> Area <br /> � 3s final Inapnction M �Data <br /> ; by <br /> Additional JpZ�` <br /> P <br /> la: -- -' <br /> Stk x6666781.6761 1:1 Loi 369-3821 ❑Manteca 823.7104 0 Tracy 8356986 <br /> Applicant Return al copies to: Environmental Heehh Permit/Services 1601 E. Hwafton Ave., P.O. Box 2009. SN., CA 95MI <br /> INFO AMOUNT DUE AMOUNT RFJe(1Tf0 CASH r RECEIVED 8Y DATE PERMtT NO. <br /> 1141331 ixEv I r -7 D. 00 <br /> Ci r42e <br />