SU0000103 SSNL - Laserfiche WebLink

Home Browse Search

. _ ,... .. .... _�.. 5,.:a.1�-+ ,-.ni;.a�_.Viz!'.. . ..'"a.�-r•i: .:9-r,a vr.' .� - • 7. R. APPLICATION F� I PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ;7; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made;o the Snn Joaquin Local Health District for a permit to construct end/cr install the work herein desCHW.TMs applierttion 12 r made in compliance with San Joaquin County Ordinance No.549 for sewage or No.S8E2`or well/pump and the Rules and Roguiatlons of the Sen Joaquin Local Health District. 3-N Trac r S flcrrs Job Address 33 D�'f1 �y� �� cityLotLot Size PM , Owners Name Address Phone ree Contractors Name Z-17 � y �`� License No. Phone i tL TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS �� INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia.of Well Casing 'yr ❑ Domestic/Pr'rvat3 ❑ Gravel Pack ❑Tracy Type of Casino Specifications O Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout ` ' t ❑ Irrigation ---Approx. Depth ❑ East3rn Surface Seal Installed by Repair Work Doner ❑ Type of Pump H.P. State Work Done Well Destruction C3Well Diameter _ ^Sealing Material(top 50') ; WF Depth __ Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is `y� available within 200 feet.) Installation will serve: Residence L Commercial_ Other j stiQ,; Number of living units: Z_ Number of bedrooms d y 7 Character of soil to a depth of 3 feet: Water table depth 3 SEPTIC TANK ❑ .Type/Mfg _ Capacity �� No. Compartments ( V:: PKG.TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well ys� Foundation %e' Property Line M LEACHING LINE R) No:&Length of lines — �r Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Daoth le" Size 10",elo, X f Number SUMPS Distance to nearest: Well /f; 'Foundation s Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,stele laws;and rules and regulations of the San Joaquin Locai H,taltii District. "! ,c, 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 shall not employ any person In such manner as to become vib,Loct to workman's compensation lbws of California."Contractors hiring or sub-contracting signature ;'; T, Certif as the following:"I certify that in the perfo-Twice of tho work`or which this permit is issued,I shall employ persons subject to workman's cow— ma-tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. SignedX- Title: Data: FOR DEPARTMENT USE ONLY D� i Application Aecep!ed by /f 7! Date Area Ph or Grout Inspection by Date Fina:Inspection by DateL Additional Comments: ❑ Stk 46g-S7S1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 83545395 ; Applicant-Rehm all copies to: Environmental Health Permit/Servicea 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 96201 k FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. + INFO EH 13-21(REV.10/83) 1 S• Ott 1�-'�3/8L, p EH 1428 1 � '7 i'71 .o-.ilb-.we�::9nIrY4'�::di' .�. ...-..e_..... �%'SiisJnlW.:..�..a...,.w...:,. �.. ,. .. _.. ... .. ._ ... ,.. :�4��i'.� •e� . IPJ•- • ~�r _il