SU0011127 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION ' SAN JOAQU III LOCALL HEALTH HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON,iCA PERMIT NO. Telephone (209) 466-6781': . DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 forwell/pump and the Rules and Regulation of the-SS JV ufin Local Health District. 1 Job Address (� (n/� n�M'�` oL6f • Subdivision Nam p t I v Address.42/OI f� d�414- Contractor �}-/�Qc- Owner's Name EGG �/ Contractor's Na License No. i3s Ica PhonP`Q(o,�-$SIO S� . 00 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE _TY?E OF WELL PROBLEM AREA _CONSTRUCTION SPECIFICATIONS _ ^.wines-..+--�--,..._-•—-".-r".--. ID Industrial ❑Open Bottom -❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack []Tracy Dia. of Well Casing ❑ Public ` ❑Other E]Delta Type of Lasing Lj Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other--"" Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State NorkJone - — - -- Well Destruction ❑ Well DiametlY - — Sealing Material (top 501) - Depth Filler Material (Below 50') - 0 TYPE OF SEPTIC WORK: •NEG INSTALLATION 0-s-REPAIR/ADDITION ❑ (No a tic tank or seepage,pit permitted if public sewer is ._. " available within 200 feet.) Installation will serve: Residence�� Commercial Y Other - Number of living units: Numberof Vedrooml., Lot size Character of soil to a/-depth of 30.eet`7 Water_table SEPTIC TANK ❑t-( TYPe/Mf9�C �. Capacity iNDC`C liimPattmentsn� PKG. TREATMENT PLT. ❑ Type/Mfg/y _1"`CaP^ a_city Method of DisposRl SEWAGE SYSTEM. n Distance'Yoynearest! Well /OD _ Foundation T/� �Property Line DESTRUCTION Total len th/size +L•EACiIY•NGtiNE+ "`—'D^-No:^i-Length of 1i es 9 r FILTER BED ' ❑ Distance to nearest: Well foundation Proderty Line SEEPAGE PITS 2� Depth a2 Size 3�0 r Number s _y SUMPS � ❑ Distance to nearest: Well /SO Foundation /� -Property Lines 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, state laws, and rules and regulations of the San Joaquin Local Health Distract., - Home owner or"hicensed egent7s slgnaEure cern f9es the full owing ceet'ify-that'in the pekarmance of the work far which this 1 permit is issued, I shall not employ any person in such manner as to become subject to w'brkmant compensation laws of California." Contractor's hiring or sub-contrwting-stgnature-certifres-the-fo4dowing.- '1--certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of-California." The applican�t\`.�nnnst ca N fqr all required inspections. Complete�ddrrawily reverse.side: DatetYT!'f7•r-�� O Signed % - \two ,f' 'm•-"-' .Ti.tle:.�- /l . �t/vR/j OR P RTMENT USE-ONLY Areayj' ❑ Stk 466-6781 Appli ion Accepted by -- Additional_Camnents: Lodi 369-3621 '""—` '"' ` Man eca'�73-7104 Pit or Grout Inspection by Date - r Final Inspection by Date ✓ y /y❑ Tracy 835-6385 Applicant - Return all copies to: Environmental He th PermI Aervvicei 1601sE.�Ha;eldon AWv, P.O. Box 2009, Stk., CA 95201 .-FEE-- BASE ' _,AMOUNT—DUE__-. ?MOUNT REMITTED_. _. _,-RECEIV,EO BY_ „ -J DATE �7 t ,PERMI�TpN�Op. INFO I $ �' ;1 -7-d - d 10/82 500 EH 13-24 REV. 10/82 14-26