SU0011177 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i • 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEA,R FROM DATE.ISSUED = (Complete in Triplicate) ll the .This made incompliance withdSano the Joaguin County Ordinan Joaquin iHealth nce No.0istrict 549 for tor a sewage or't to construct and/or No. 1862 for weii/pump atnd the Pulse and(Regulatioin ns of he San'cation is Joaquin i Local Health District. e Job Address o�SfrD city',21 Lot Size Y/�M,�.If Address S/in +v^ Phone Owner's Name .�.,�..�� 11 w Address ��-aA License No Phone 4 Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O 'SYSTEM REPAIR ❑ OTHER ❑ DISPOSAL FLD. PROP. UNE DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES tt FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casing ❑ Industrial ❑Open Bottom C Manteca Dia. of.Well Excavation Specifications Domestic/.Private. ❑ Gravel Pack C1 Tracy Type of Casing Type of Grout_ ❑ Public ❑ Other r Delta Depth of Grout Seal I I Irrigation —Approx. Depth LI Eastern Surface Seal Installed by " Repair Work Done ❑ TV"of Pump H.P. State Work Done_ Well Destruction ❑ Wen Diameter Sealing Material(top 501 ,Depth Filler Material (Below 601 iA t TYPE OF SEF: WORK: NEW INSTALLATION I1 REPAIR/At4D1TION ( DESTRUCTION I 1 available within 200 feet�)(No septic system permi �if public sewer is 0 '• Installation will serve: Residence 1_1 Commercial Other Number of Irving units:� Number of beddrroo hh F - A .Water table depth Character of soil to a depth of 3 feet: - ! SEPTIC TANK ❑ Type/Mfg _. 1 Capacdy__/_ f z-= No. Compartments •/ ,_ C^ Method of Disposal PKG.TREATMENT PLT.❑ - -^f'�"^"'+: f% _ -- - - "Distance to nearest: _ Well rEL(Z_ foundation..— PropertY�Lirier �^�,,, . Tota.,,sll engthagEa ^LEACHING LINE No.& Length of lines "��e � r, _ FILTER BED Distance to nearest. Well ^: Fo undation`s�.Lt—I partY-L'ine ' SEEPAGE PITS I I Depth 1D FT Size�,�' di�-.�� +! Number SUMPS" Distance to nearest:f" Welloundafidn�fT . Property Line�`oc — 1 DISPOSAL PONDS ❑ . I hereby certify that 1 have prepared this application and that the worn will be done in'ai'dordan'Ce with San Joaquin COUMY ordinances, sista laws, and rules and regulations of the San Joaquin Local Health District. - ' 110 Home owner or licensed agent's signature cartifies She following:"I cartifythbt iR"ih6'pe7forma ofVhe'work for which this Psit is issued, I shall not employ any,parson in such manner a5 to becorne;subject-to-workmen's;curnpensation fawn-qf Califorroa."Contractofs hging or sub-contracting signature certifies the'following:"I cart1fV that in theperformence of the bhiiWfor WftiG+)his Permit is issued.1 shall emptily persons t ubject to workman's wmpensa- Hon laws of California." '`: { '�''✓ -�� The applicant must call for .114a.qu nspectorls. Complete drawing pn,raverse side: s • 1 S7- 7 t' - .oa —'Date: Signed N�= •sz�r�--•Tide:�;_. r. • i RTMENT USE ONLY Am /�+ 11 Det j Applicetbn Accepted by t Date Pit.cr Grout Inspection by Date Final Inspection by, . i rAr i Additional Comments: _^ ❑Stk 466-781 ❑ Lodi 359.3621 Cl Manteca 823-7104 ❑Tracy 835$385 Stk C 95207 ` i P.O.Box 2009, Applicant/Retum a8�eopies to:1E�lvironmerital Health Permit/Servicer:1601 E. Hazelton Ave., . / ? 1 w..,.....°+;•� �„ „"FEE_ AM LINT 41UEar�. --AMO NT•REMITTE �+---C -^—REC{rVED•BV ,DATE' `�'PERMR'NO� r INFO'.""' .»_.. . .. f. _ _ kyr w ••4.L:. ..i.i�'�.Tw w+n+�•.w4`�Lmws`w..•r-_�-.a- ._ ..EH ts'61 IREV.1/As1 -Cisq�~ Off. . 01%2e ..