SU0008936 - Laserfiche WebLink

Home Browse Search

APPLICATIONiFOR PERMIT ,i`Lti^JISJVE 3�jUt _ 21984 LW 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA SAN JOAQUIN LOCAL Telephone (209) 466-6781 14MTH DISTRICT, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -(Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fore permit to construct and/or Install the work heroin described.This application is , made in compliance with San Joaquin County Ordinances No.649 for sewage or No.1862 for well/WmP 6 and?�DO'�and R®u�t'orm of tits Sen Joaquin Local Health District. .rr_:if' t ::(1 `-7 D75 "` y i-. - X 9 City a C 12d4be Job Address aqa 6L c vy—a— M 'A(�iMddress `+ Pito Owners Neme �ny ,` �Y `5 - V 7 � Contractor's Name "� "`f`- � �S 54 LJCense No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 9--� SYSTEM REPAIR ❑ OTHER ❑ NSEWER LINES -Int�7- DISPOSAL FLD. PROP. LINE _ DISTANCE TO NEAREST: SEPTIC TANK « AGRIC(JL'fIJREYt/El1",";" OTHEf�WELL- '� PITS/SUMPS— •,. •, - Z�.: :.'-"FOUNDATIONc."'P „ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casing I -❑ Indunnal pen Bottom ❑ Manteca Dia. of Well Fxwvation Type of Casing_ GI-' �. _ SpecrFioetionS . ( J 1 QJAomestic/Private ❑ Gravel Peck ❑Tracy s ❑ Public (0 Other 7) Delta Depth of Grout Seal �M Type of Grout ❑ Irrigation /�yy,�kppmx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done C1Type of Pump 5"6 H.P. 3 State Work Done— v� Well Destruction ❑ Well Diameter Sealing Material)top 501 Depth Filler M8ledel [Below 504 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ avail UP whM1 nam feet.)ed if public sewer is Installation will serve: Residence_r Commamial_ Other t j Number of living units:— Number of bedrooms - Water table depth L Capacity Ii Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT.❑ - `Distance to nearest: Well Foundation property Lina LEACHING LINE ❑ No. 8 Length of lines Total length/size t °❑ Distance to nearest: Well Foundation Property Line r FILTER BED .� Number SEEPAGE PITS C] Depth $13e -- SUMPS , El Distance to nearest:. Well -iFoundaiion- Property amine- —� y` DISPOSAL PONDS ❑ / 1 hereby certify that I have prepared this application and that the Work will be done in accordance with San Joaquin county ordinances, state lewa, and rules and regulations of the Sen Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is Issued, I signature shell not employ any person In such manner as to become subject to workman's which this sWn laws of Cal*d,I ShallContractor's ploy c ons subject lubl�to worktmaniscompenss- cenifies the following:"I certify that In the performance of the work f«which this permit is iwued,I shell employ pe tion laves of California.- The applicant must call for all required Ina 'ons. Comdata drawing on reverse tide, L�s Dole- Signed -�/� FOR DEPA Ni USE ONLK _ JO-�� Application Accepted by :. J— Date_y/ "f- ' rsa IL p Final Inscuon by Gr G"�Dna Date pe1J Pito Inspection by Additional Comments: ❑ Stk 4668781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-BM Applicant- Return all copies to: Environmental Health Permit/Servicae le01 E. Hazatton Ave., P.O. Box 2009, Stk., CA 95201 TEE AMOUNT DUI AMWNT REMITr11 GSH RECEIVED 9; DATE PPEGER��MIT'NO. INFO -/ al-91-0- .W M tea In”.toren Z _ P EX W25