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SU0003175
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2600 - Land Use Program
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SU0003175
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Entry Properties
Last modified
6/14/2022 6:55:35 PM
Creation date
6/7/2022 9:34:10 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0003175
PE
2633
FACILITY_NAME
SA-92-09
STREET_NUMBER
889
Direction
E
STREET_NAME
ROTH
STREET_TYPE
RD
City
FRENCH CAMP
ENTERED_DATE
11/6/2001 12:00:00 AM
SITE_LOCATION
889 E ROTH RD
QC Status
Approved
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SJGOV\sballwahn
Tags
EHD - Public
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P <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1801 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 488-8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/a irtatM the work ltareYl daaeffbad.Thk apIlikom k <br /> made in compliance with Sen Joaquin County Ordinance No.50 for sewage or No.1882 for wall/pump and the Rule and Raouklktta of#4 sm denfaM <br /> Local Health District. <br /> p p p <br /> Job Address O (JJf iCc 70` city Lot Sine PM <br /> ! � dPfwM 1P RZ <br /> Own 's Name � <br /> Contractor ,'��/Qi����< < dress �n Lt��/ Lkense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION O <br /> PUMP INSTALLATION)a RAr4.,ret�_ YSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK --- SEWS LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIG.+1 _ AGRICULTURE WELL ._ OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ;Industrial r I Open Bottom (I Manteca Dia. of Wall Excwation Ow.of waft Casing <br /> Domestic/Private a Gravel Pack f , Tracy Type of Cs*q _ SPGCMD M M <br /> Public C Other ❑ Delta Depth of Grout Seal TWO d Gloat <br /> Irrigation --Approx. Depth rp❑ Eastern Surface Seel I stallod by — <br /> Repair Work Done C. 'ripe of Pump �t 11L�— H.P. .3 -- State Work L Das�-AU 'O F45f 77L G <br /> Well Destruction 7 Well Diamwor Saalkg Material(top 50'1 <br /> Depth_ Filter MotwW IBalow 50'1 /VFLtJZiCIIS_ - <br /> TYPE OF SEPTIC WORK: NEW INaTALLATION U REPAIR/ADDITION LJ DESTRUCTION 13 ,yOM'Ni0 ayaMnl ) 0 grONC www is <br /> \ wNl�l <br /> Inst llo—t wiN serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms_ <br /> Character of soil to a depth of 3 feet: w tat tabs dwh <br /> SEPTIC TANK C' Type/Mfg Capacity No.Colrgw!I Neta <br /> PKG.TREATMENT PLT.7 met! d M Dkpoaal <br /> Distance to nearest: WoN Foundation P►oPeRy Lina <br /> LEACHING LINE C No. 8 Length of linea ToW Wgth/alae <br /> FILTER BED Distance to nearest: Well Found~__ ProPM1y Lina � <br /> SEEPAGE PITS Depth Sirr _ t�ur►nbM <br /> SUMPS Distance to nearest: Well Foundation Pnrpagr Lits <br /> DISPOSAL PONDS <br /> 1 herby certify that I have prepared this application and that the work will be done in Occc"bra with San Joaquin county oldetartCla am laws,and <br /> rules and regulations cf the San Joaquin Local Meahh District. <br /> Home owner a licensed agent's signature certifies <br /> following• "I certify that in the parPoo rttanee of the work far which this pw"*11111 atrad.I altd not <br /> em+Dby any person In such manner as to become subieet to workmon'1 ion oomq-ww wws of California."Con"ecto✓s hiring or sub-contraeung alpnMlE� <br /> certifies tho following:"I certify that In the performance of the work for~oftpermit is rowed,I shall employ parsons subjacl to womft~1 oanlpatlM• <br /> tion laws of CaBfomis." <br /> The applcar. NI r all r inspecto_ns. Coo, to drawNg� � _— Title: on <br /> J ~ � ane: <br /> Signed X � �l <br /> le <br /> FO DEPARTMENT USE ONLY �� Arne �t> <br /> ,�Awk)n Accepted by ;��7Dab <br /> P.t or Grout Inspection by Date Finch Inapeetfon len <br /> AdJitlo:emnt <br /> l Comes: <br /> Stn 486.8781 ' Lodi 309 3a2t Madsen 823.7104 Ll Tracy 8354= <br /> Applicant • Ratum an copies to: Environmental Health Poomi/Serv►ces 1001 E. HarWon Ave.. P.O. Box 2010, Stk., CA NMI <br /> FEF AMOUNT DUE AMOUNT f1EMITTiD t�►SH AECEM_o air DATE rEftaat! NO. <br /> INFO <br /> Iw 174.Ary <br />
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