ARCHIVED REPORTS_XR0012635 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR.Pk'RMI'T' SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE.. STOCKTON, CA R1EC `1VF!1 Telepltafle 091 4664MI MAY 11119q PERMIT EXPIRES 9 YEAR FROM DATE ISSUED S N JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVICES hill ONWI �NTAL ! ATF VIS . Application:3 hereby«tide to the San Joaquin Local Health Diatrict for a permit to construct and/or inn en r nude in compiwroo with San Joaquin County 0rdin4nce No.50 for aowege or No.1982 for welt/pump and the Ruled end ltegLdatiorr of the Sart Joaquin Local Health Oisrnct. Job Addross -��1"s �1(� �fl o City Lot SincQ..�PM Owners Name 1 ov ks ye 1 •4 •60", !:Boni1� Contract Address Llt cress No. - TYPE OF WELLfF'UMP: NEW WELLX, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL— P1T$/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA _CONSTRUCTION SPECIFI I1PNS �r C Industrial 0 Open Bottom ❑Manteca Dia.of Wer Exraystion tt�— Dis.of W04 C Domosticiprivata W tavd Pack ❑Tracy Type of Cortin Sperlfieatioru 4.+! C Public 091. 0 Delta Depth of Grout Ser � Type o/Grout C r tS5-�Approx.Dapth P-ESatem Surface Sad Intl d by Gofrw c P ❑ Type of Pump M.P. . Stance Work one- - -- Wei Destruction ❑ Wali Diameter Sasling M.-trid(tap 50') Depth Filer KaWial 15elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 13 DESTRUCTION❑1No septic system pemvtted it public sewer Ls available within 200 loot.) Installation will serve: Residence— Commercial_ Other �. Number of Hying units: Number of badrooas Chwactar of eoi to a depth of 3 feet Witter table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments PKG.TREATMENT-PLT.❑ Method of Disposal D'asance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.A Length of linos Y Tour lorgthlpita FILTER RED ❑a Distance to nean4t: War Foundation— Property Line SEEPAGE PITS ❑ Depth Sita Number SUMPS ❑ Distmes to nearest Well Foundation Property Line DISPOSAL PONDS O I hereby cattily that I have prepared this application and r-at the wort will be done in scoordartcs with San Joaquin country ordinarn'",stats la tis,and -- ruins and reputations of the San Joaquln Local Has"Dhuict. Herne owner or irmrcted agent's signaNxn attNiea the forowing:"I ow*that in the penfamance of the work for winch thh pertriitt is sued.I after not rrpfoy any pereo n in such marcher m to bscorne wbleci to nacrkrnen's e>ompertwtion hates al Calilomia."Contrsctora hirirq or eut>u�rttractirtg signature certifift the f Wowing:"I comity that in this poeforrrtanee of the twork for which this partrit is issued.1 altar employ persona wbjset to wank—'s corr>Qarsa- tion laws of CoNamis." The applicant n call r all carred hupectiors.Complete drawing on reverse side. Signed Title. 1 Oe'N Date:qTvvt �' Fo • W 7Y T. 'n O cPAawiMAIENT u clalt`r Application Aoapad by i, lL.. r.• I; .. • 1 Dsts Area It �» Pit or Grout ktapactfon by Oast Final Inspecdco by Date - Addetiottal Comment: ❑Sik 19&9791 ❑Lodi 389-M1 ❑Mantes 823-7104 C7 Tracy 836M _. Appbwt-Return ar copies to:Emfomsntal H"th Pann0t1$rvicae 1001 E.Hatelton Ave.,P.U.Box 2009,Stk.,CA 96701 F" AfdOtfNT DUE AaA0t1NT RLafl1TED RECEnao BY DATE PERWT'No. INFO y.. roc kOlA-64- q-'jSSM .eNts7autv.treen �1 '�Si. OD ��