Laserfiche WebLink
APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT F <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA • <br /> l Telephone (209) 468-Ml �,-Pii�'v <br /> ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hneby made to the San Joaquin Loral Health District for a pamit to r»ratruct and/a itatellMro wodcherdn deactUred.rws application is <br /> ' made in complbnco with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rubs and Regulatlaa rd the Sen Joaquin <br /> Local Health District. <br /> Job Address _p �~�7 / �G-�,[G/rL zl�- Caly /� Lot Size,, ,Qf[/J 7,eM <br /> fO?t�P <br /> OWnars Nacre s. �^�•/1- �A/ddress 1. . !(i/I Z! 4C, C.i�7.-p!yprpng / 0 <br /> Contractor 7jfc-/ <br /> t• Uri � ,&//Address T��S 1,/K.NGTY/.Git Licerae Not _s G Phone "�f7 <br /> ' TYPE OF WELL/PUMP: NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRULMON ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SENK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> ' FOUNDATIO AGRICULTURE WELL OTHER S/SUMPS <br /> INTENDED USE TYPE OF WELL PR AREA CONSTRU IFlCATIONS <br /> ❑ Industrial ❑ Oren Bottom ❑ Manteca WeU Excavation, Die. of Wall Casing <br /> ' ❑ Domestic/Private ❑ Gravel Pack ❑ T Type ng Specifications ^� <br /> ❑ public ❑Other ❑ Ddte Depth of Grout Type of Grout lv <br /> ❑ Irrigation ox. Depth ❑ Eastern Surface Sed Installed by ell <br /> Repair Wak Done ypa of Pump H.P. _ State Work <br /> t Well D ❑ Well Diameter SeelinQ Matand(top 50') <br /> Depth filler Material (Below 500) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDI71ON ❑ DESTRUCTION❑ (No septic system permitted it public sewer is <br /> ' r Installation will serve: Residenavailable within 200 feet.1ce Commercial_ Other_._ <br /> Number of living units: _./. Nurnbr rr!-Ilredroorgs <br /> Character of sol to a depth of 3 feet: ! ®A- n Water table depth <br /> ' SEPTIC TANK C3 Typa/Mfg i � a t'/7P�'i. Capacity /.[Yv 9R!- No. Compartments <br /> PKG. TREATMENT PLT. ❑ / / Method of <br /> ' <br /> Distance to nearest Weell/�� Foundation 5Q_ Property Line J LEACHING LINE No. & Length of lime a D Tmal length/size <br /> FILTER BED ❑ Distance to nearest: Well/ro , Foundation !iD _ Property <br /> ' SEEPAGE PITS ❑ Depth _Stn Number_ <br /> SUMPS X Distance to nearert: Well ft O Foundation 4-4;--& -' Property Line >Az'-A--3 <br /> DISPOSAL PONDS O <br /> ' I hereby certify that I have prepared this application and that BIe work will be done in accordance with San Joaquin county ordinances, stau laws, and <br /> rubs and regulations of,the San Joaquin local Health District., <br /> Home owner or licensed agent's signature,certifies the following:N certify that in the performance of the work for which this permit is carred, 1 Wall not <br /> employ any person In such manner as to become subject to workmen's compensation laws of California."Contractors hiring or subcontracting sigrotum <br /> cartif last the following:"I certify that in the performance of the work for which this permit is" I MuM employ persons subject to workman's corn pe <br /> ' tion laws of California." <br /> The applicant m ,lcJ� f/orJ(aU/rpeq�Wre/plygfleetlens�. Cq/typlate drawkq on ansae side. <br /> Signed x•"�?�i� '!/ 4'1r_%/�/7Src/tGf rNe: �Lr- it Date:._Y'ZZ <br /> FOR DEPARTMENT USE ONLY <br /> ' Application Accepted by ,l Dao 7� Arias .� <br /> ' Pk a Grout Iropsction Dab T' Z Fires!Inspection by T\UIYJ� <br /> Additional Comments: <br /> ❑ Stk 43S-M1 ❑ Ladd 369-3821 ❑ Manteca BZI.7104 ❑ Tracy 66.6385 <br /> Applicant- Retum all Copies to: Environmental Health Permit/Services 18D1 E. Hat~Am., P.O. Boa 2009, Sit., CA 9=1 IF <br /> INFO AMOUNT DUE AMMINIT REMITTED CJ1SH RECEIVED BY DATE LPEtMIYND. <br /> Fit r12r aEw.1/a e1 O, U. <br /> Ea 1Ala <br /> r <br />