SU0005179 SSNL - Laserfiche WebLink

Home Browse Search

a✓ " APPLICATION iJR PERMIT SAN JOAQUIN LOCAL iiEALTH DISTRICT 1501 E. H.AZELTON Ae:t-.. STOCKTON, CA ' PERMIT EXPIRES 7 YEA'r. ::ROM DATE ISSUED Complete In -plicate) i Application ::hemby mad.:to The San Jpde1 n t^uP HCnlih D at-rt Iv'a; in rms,rucf a,alar natdll lha wort,heren rle'cnbed. Th.sSan pm rt. tirr 4.e n r' made in cw�pl ancc with San Joaquin Co,mty Ordnance No.569 for sowage or u. 1862 for woupump and the Rules and Regulations of the San Joaquin .� i.' Local Health District. Job Address ,�'./ Ciity^--�Z�L-- Lot Size PM PM .8 Owner's Name .[//�4� Address a Coalractar_QAllows., License No._____-_.__Pnonc_ —_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPG+CEMENT is DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES __ DISPOSAL FLD. PROP. LINE `N _ FOUNDATION AGRICULTURE WELL OTHER WELL—_. PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS 5 ❑ Industrial ❑Open Bottom ❑ Manteca Dia. o1 Well Excavation __ Db.of Well Casing ' ❑ Domestic/Private ❑Gravel Pack ❑Tracy Type of Casing Specifications ❑ Public ❑Other ❑Delta Depth of Grout Seal ____ Two of Grout_ ❑ Irrigation --Approx. Depth rl. Eastern Surface Seal Installed by--.--- Repair y_ — Repair Work Done ❑ Type of Pump -- H.P. T State Work Done_ Well Destruction ❑ Well Diameter Sealing Material(top 501 _ ` Depth_ Filler Material(Below 501 _ TYPE Or SEPTIC WORK: NEW INSTALLATION❑ REPAIR/AD01710N IV DESTRUCTIOP; ❑ (No septic system permitted i1 public sower is available within 200 feet.) Installation will serve: Residence-k_ Commercial_ Other — !4., Number of living units: Ir Number of bedrooms_2-_ I%f0� Character o1 soil to a depth of 3 feet:_JY7G£J Water depth SEPTIC TANK �Q Type/Mfg -tK--f/ A� t S �+ — Capasity1�Up_ No. Comoampartmenu a r. PKG.TREATMENT PLT.C7 ( Method of Disposal — al i Distance to nearest: Wall_� Foundation lt7r Property Line I LEACHING LINE IJ( No.&Length of linea � Q pTOIaI IBpOt11/5138 1 �r✓�-�/L 1 FILTER BED ❑ Distance to nearest: Well ��.1 Foundation—Lsr_ Prop eM LirlA �� SEEPAGE PITS �' Depth _ Siae_—.L�__ Number--! T— I SUMPS ❑ Distance to nearest: Well/QO/ Founda:ion_ZOO" Property Line "r 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 I rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this permit is issued,I shall not 1 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followi :If certify that i he performance of the work for which this permit is issued.I shall employ persons subject to workman's compensa E tion laws of Calif. nis." <, The applicant of cal or all r ired inspections. Complete drawing on reverse side. Signed X Title:_Q Cr h o Data: %2_3 FOR DEPARTMENT USE ONLY 1 spot) tion Accepted by Date_/2__ "- Area_1J Pit or Grout Inspection by _ Date__ _ Final Inspection by_ Date i Additional Comments: ' { ❑ Stk 4666781 ❑ Lodi 3693621 O Manteca 823.7104 ❑Tracy 8358385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ava., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED flELEIVED BY DATE PEflk11T'N0. INFO H ♦EN IZ11flEV.+rx51 J $, to J,-S. C^T. - 3 t� � SS-IS-75 EN13N Ck`t lo. Ia)