SU0001237 SSNL - Laserfiche WebLink

Home Browse Search

vow Ca, JCACL,L LOCA. -icLTH :;S-41,T i 1601 E. nAEELTO1. AVE., STO(STON, CA PERMIT r'0. Telephone (2091 466.67SI ppiE ISSUED / aZ i^ PERMIT E%PIRES 1 YEAR FROM DATE ISSUED ♦. 'y\j (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicatior, is made in co pi iance with San Joaquin County Ordinance N.M. 549 for sewage or No. 1862 for wellyPupp b and the Rules and Regulations of the San Joaquie 14alth District. - d All Job Address � 5� AlaA><,Q/�*+Local�� Subdivision Nam Owner's Name n,46,4 � /inti Address `Q L��,[�j.LP,/a... We Contractor's Name . /-.//-cr_2 License No. : Phone v+ S is TYPE OF NELLi DVMD WORK: NEN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L—,) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE_� W FOUNDATION AGRICULTURE WELL OTHER WELL P1T5/SUMPS 1, INTENDED VSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0' ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation .J Y; ❑Domestic/Private ❑Gravel pack ❑Tracy Dia. of Well Casing "J +; ❑Public [/Other ❑Delta Type of Casing J (_j Irrigation ._ Approx. ❑Eastern Specifications _ :(a ❑Catholic Prottttion Depth Depth of Grout Seal W, ❑Geophysical i Type of Grout 17 Other Surface Seal Installed by Re pa ir Work Done❑ TY>r of Pump — X.P, State Work Done f Kt Well Oestructi on❑ Well Diameter Sealing Material (top 50') s ` ( .Depth Filler Material (Below 50') ry TYPE OFISEPTIC WORK: NEN INSTALLATION U REPAIR/ADDITION X (No septic tank or seepage pit Permitted f1 public saarar 1s'w'rx 19"available within 200 feet ) ..'.' Installation will serve: Residence ✓ Commercial Other 1 Kimber q1 living units: Number of bedrooms Lot site u:( Water cable depth _ Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK Type/Mfg Capacity Capacity Method M Disposal _v PKC. TREATMENT PLT. Type/Mfg SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION C] F T T Totalength/sire ia FT LEACHING LINE jQ No. 8 Length of lines F l �_ L FILTER BED [LLJ`. Distance to nearest: Well Foundation Property Line .'lu SEEPAGE PITS [] Depth Site Amber _ Property Line SUMPS U Distance to nearest: Well Foundation DISPOSAL PONOS [I I hereby certify that I Piave prepared this application and that the work will be done in accordance with San Joaquin county -�. ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for watch this permit is issue0. [ shall noL employ any person in spch manner As to become subject to workmant compensation lows of California.. sub-contracting signature certifies the follOwlnn: "I certify that in the performance of the work for which Contractor's hiring or sub-co this permit is issued, i Shall employ persons subject to workman's corpenSetion laws Of California." The applicant must cal je 11 required inspections. Complete drawing'n reverse side. Date: Signed % Title: - FOR DEDARTMERT USE ONLY Area �_ ❑ Stk . 466-6781 Application Accepted by / 1\C ❑ Lodi 369-7621 Additional CD^mens: _MentpK a 827-TIW Ja _ �Y Pit or Grout Innpttbon DY ❑ Tra 875-6385 -- v �Cfv rate Final Inspection by r H p,0. Bar 2009. Stk., CA 95201 Applicant - Return all conies to: Environmental Healtn it'Services 1601 axeltgn Ave., I RECEI'1ED BY DATE PERMIT NO. I1NFO (BASE A!i;Ut1f DUE AMOUNT REMITTED �' qTj Q3-/b 71 _ 0 \oi+vl/jam IWn2 500 EH 13.24 REV. 10/82 - 1i-26 601