SU0002754 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT _ %a/SAN JOAOUIPJ LOCAL 011ALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Noose ± Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE 18217ED Fit (Complete in Triplicate) Ilcetinn is 7 AppiiCaY n is hereby made to the San Joaquin Local Health District lora Permit to construct and/or install the work ain!.scribed.Thin a 4 made in Compliance with San Joaquin Cmmry Ordnance No.5491 n,sewage or No.1862 101 well/Wmp and the Rules end nd H•��Jauom of Me Saa �n Joaquin t _ Local Health District. PM Job Address ^ � ^L City f Phone Owner's New �f A rasa -- �J �f ��7 7A License No OE'. -Phe��.. Contractor_J" �1 �l L'Y Address�1�� a NEW WELL r1 - WELL R PLACEMENT ❑ DESTRUCTION L' TYPE OF WELL/PUMP: PUMP INSTALLATION 13 SYSTEM REPAIR O -OTHFfl'❑ r I DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD.__-PROP.LINE FOUNDAI:CV AGRICULTURE WELL — OTHER WELL—�PITSiSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia Well Ccshtg ❑Open Bottom ❑Manteca Die.of We,,Excavation ❑ Industrial _ Specifications TtacvType of caning r ❑ Dornesticl Private ❑Gravel Pack rl Dela Depth or Grout Seal _ Type d Grout_ 1 n Public Il Other ^� —Approk.Depth I I Eastern Surface Seal installed by e 4 I I litigation $tate Work Dore M.P. Repair Work Done [3 Type of Fump Sealing Material(top 5D') --�— Ws1 Deatruc'ti6e` - '❑ Well Diameter _.. - Filler'Asteria!!Below 50'1 Depth n . ` "I TYPE OF SEPTIC WORK: NEW INSTAlLAT1ON I I REPAIR/ADDITION DESTRUCTION± avadablelwithin 203 fast d it public sewer n CCommercial j Ih +'..'mion will serve: Residence_. Other •t i i n r Number of bedrooms FLImbet ,i.vine units:� C a e yn Water Is01e depth _ ` - 1 Character or yd!o a depth of 3 feeC 1 Capacity- No.Compertmenn SEPTIC TANK L7 Type/Mfg _ t Method of Disposal PKG. TREATMENT PLT.O n�s_�_� Property Line g�s�r -Dista•ce m newest: Well 6(L - Foundation 19 ;`'� - n m es IMM Wn1I Total Nrtpth/wx — x�Dd i LEACHING LINE ❑ No.8 Length ritr -� Foundation ❑ Distance to nearest:. 4 � FILTER BED size_-- Nrmher SEEPAGE PITS I I Depth Property SUMPS Lkta:. Ll Distance m nearest: Well __ FougCation _I DISPOSAL PONDS ❑ n oMinances,state aws, and 1 hereby certify that 1 have prepared mix apolleation and Mat the work will be done in acco•dance with San Joaqukr tmu ry I.had not - rube end regulations of the San Jona tine Local the following; I.artily that in the p,dormanee of the work for which this permit is issued, _ g; .. Home owner or licensed agent's sig neons subject to wr:rkrrun oorroatue employ any D ,non in such manner es to lxcome sublart to workman's compensation Tawe ss ed,I shall emP1oV pe ra hiring Cr to wc,knem's signature j Certifies the following.•9 Certify that in the performance of the wcrk for which this permit is issued, ; 7 tion law,of California." �.I The a jpljCam must call for all r uired in coons. ComP:efe drawing an mver:.a side /. 1 _Title:kill" .�,C• �� - Date: !1 it%— jgcR DEPARTMENT USE ONLY O _ Date �- Aron._ ) -Application Accepted by _ Data { Dat. F, at Impac!ion DV tt ptw G +t InalxeCTion by A460011sl Con lmntr _�-_ - _ #r 36g_�1 ❑Manteca 073-, _ ❑.Tracy 875-5785 1 / C k x66678:__._ ❑LON_. _ - Applicant-Return ak aip(as to: Environmental Health?mmit/Sernces 1601 E.Nex0lton Avs.,P.O.Bos 2009,Se'. %A 95201 3 4 _ , PE5s1R•NO. L � CK RFCEn/ED BY _DATE FFEE AMOUNT DUE AMOUNT R!MITTED /� 7 90 ,70=�-O7 i 0- t -Dr o c7 L a