SU0006056_SSNL - Laserfiche WebLink

Home Browse Search

APPL'CA PION I.OR PE' 1'T SAN JOAQUIN LOCAL :IEALN.96ISTRICT 1601 C. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR_MOM_DATE ISSUED _._.__--_..•—(Complete in Triplicate)�----__-- Application is herobv made to the San Joaquin Local Health District for d permit to construct and/Or install the work herein describ-J.This appficatinn it made in compliance with S:m Joaquin County Ordnnancu No.549 ton w—po or No. I862 for wevinimp ant,the Runs and Regulations of the San o:lut. Local Health Uisf:,ct. / eC�V V �__�' _ City-_ Iof Size 200— PM Job Address _ _u_ {� _ __ Address __c Owner's Name iFa Me. _ Phone 2 3el" 1110 . _ - --- - - --- J o if3:�iTo N flu 2489 r 3669 ConUactor�1 M CAR _ �_License No. Phone C.,Le- Address -- --- hi TYPE OF WELL/PUMP•:,_._. ,_ _._.NEW WELL J. WELL REPLACEMENT Cl DESTRUCTION U i — 'an PUMP INSTALLATION ❑ SYSTEM REPAIR 171OTHER O ;+ DISTANCE 70 NEAREST: SEPTIC TANK _. SEWER LINES DISPOSAL FLD. PROP.LINE FOUNDATION AGRICULTURE WELL OTHER WELL— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C_ONS'fR_UCTION SPECIFICATIONS ,4{ Dia.of Well Cain 17 Industrial CI Open Bottom ❑Manteca Dla.of Woll Excavation fl y Type of Casing ` Specifications M I:)Domestic/Private C1 Gravel Pack I.7 Tracy fl �2 Cl Other (•I Public 1-1 •lelta Depth of Grout Seal __ Type of Grout_ - Irrigation __Approx. Depth I I Eastorn Stir lace Seal Installed by State Work Done 2k, Repair Work Done [J Type of Pump ___—_—. H.P. tWell Destruction 1] Well Diameter Sealing Material(top 501 -- 1 - ! Depth Filler MaterialI8alow 501 -- r^y ,4 TYPE OF SEPTICWORK: NEW IN I I REPAIR/ADDITION Ir DESTRUCTION( I availabPeNo rw Thin 200 feec system Lled d publin,fewer Is Installation will servo: Residence— Commercial_ Other Number of living units-__ Number of bedrooms �fsr Water table depth �p Character of soil to a depth of:1 fent:_ +t�7 Y, _ Capacitv__ No.Compartments SEPTIC TANK ❑ Type/Mfg __ Method of Disposal _ e l 7 rt +t PKG.TREATMENT PLT.f.1 Distance to nearest: Well Foundation Property,Line r r �J LEACHING LINE CI No.8 Length of lines Total length/size - Progeny Line' FILTER BED LI Distance to nearest: Well Foundation i 0 d(L �b Number SEEPAGE PITS I I papth _Sire SUMPS , w/ r 30 r Ntme' - Distance to nearest Well�0_ Foundation Proper r , >k DISPOSAL PONDS Il I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws.a d rules and regulations of the San Joaquin Loc Health District. F•..:f p l I nit ;i2 a '.'r eine 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 shad not employ any person in such manner as to become subject to workman's compensation IaMK of California Contractors hiring csub-contracting s+gnatsa- a ` certifies the following:"I certify that in;ihe performance of the work for Which this permit is issued.I shall employ persons subject to workman's co tx nsa- tion laws of California." r N' The applicant mu all for all requiredins coons.CompYete drawing or,reverse side. -tl Fri., pkv, ,Lv,i6 l _ tJ/y��,_ t7 CS I f`/1!'sit• -- s•/`� Title. Signed X - - FOR DEPARTMENT USE ONLY ! ` —k— b Date Application Accepted byb !�ks Date Pit or Grout Inspection by - Additional Comments:, 1 u C Stk 466.678? l D Lodi '369.3621 O Manteca 823-7104 ❑Tracy 835-6385 „Applcant, Return all copies tu:Environmental Health Permit/Services 1601 E.Hazelton Ave.,P.O. Box nOrYl,Stk., " 15201 r4 t n W FEE C RECEIVED By GATE PERMIY NO.- AMOUNT OVE '.•,MOUNT REMITTED H i ;n ��t•t �'y `' INFO rt V vy�j� E H 13.2 InEv.v+sr O E H 1.29 41 1xzIr ! ^*Y r .;,rr!„,u{4k •4'Fr.a, ix to .r'. • L L w 4 y '' I i•