ARCHIVED REPORTS_XR0011578 - Laserfiche WebLink

Home Browse Search

z APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E. HAZE; TON AVE., STOCKTON, CA Telephone (2094- -67�f PEFIMIT EXPIRES 1 YEAR FROM DATE ISSUED _ . . _---••-- .(Complete in 7riltilc:ttel x y� Apphc.rtinn r: hi-why inane to the San Aoac.wn local Health D+stiicl If), a rtemw to r,onsinicl areal/or instill the work hrercin described This apnlirahnn is rri.lde nr r omphanr.c Willi Sart.luailtrrr)(:rrt,nry t iom,incu No 549 Inr sewage ur I`Jo 11162 for well/puiT,p JnlI the I4ules anti Rer)crlations o1 trio S:in Jnarlurri Local liealih Drttncl. Job Address ap r _ xA H /i'yl L/�U�� City rii"C r Lot Sire PM 7- Owner's Name ��r � 0. �I'+-�a�1 In Address 3�U W�� 190 S' Phone��I�._Z Contractor _V y`> ` t f'��L I Address Al _ _ _._ F ;, License No. Phone /6 TYPE OF WELL.-PUMP: NEW WELL .1 WELL REPLACEMENT DESTRUCTION i7 PUMP INSTALLATION SYSTEM REPAIR t.1 OTHER �o Bot. rt cf DISTANCE TONEARFST SEPTIC TANK SEWER LINES .. ---_-. _ __ DISPOSAL FLD .-- --- PROP LINE ' _... ... FOUNDATION = — AGRICULTURE WELL ._-_ OTHER WELL 3C_�=PITS/SUMPS _ INTEfJ0FD USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I i Industrial CI Open Bottom l.3 Manteca Dia. of Well E,cavat4on- Dia. ctf sFgAL�z7rrg __ -._ .- ' DoriiesticrPrivme 1-1 Gravel Pack Tracy Type of Casirxl _ Specifications Prihhc ' 0111r•r Delia Deplh ill Grortl $t-al Type o1 ('iooi InnJarion ._ Apluna. Depm Edslufn Sulfacu Suit Installed by kv -D!elzL!HG-_ ,- - - Ftepdu :York f]iine Type of Purnp __-_------ _ L1 P ._-_._�, - _ -- -- Swu: Work Done --,- ------ Veil Destruction W01 Diameter Sealing Material Itop 50'1 A��r ANT G,POu7"' /� Depth -_ V �� Filler Material tBelow 50'1 TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic systern permuted it public sewer I$ available within 200 feel.l Installation will serve: Residence Commercial — Other Number of living units: _ Number of bedrooms Chaiar,ter of sod to a deplh of 3 feet: ._ _ ------.-----_--.- ---_---- -_---___--, ___.---Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal -- —_ Distance to nearest. Well _ Foundations Property Line ' LEACHING LINE -- 0 No.& Length of fines _-- Total len.) /size .---------- FILTER BED 1.1 Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS i I Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Properly Line ' DISPOSAL PONDS 0 I hereby cattily That I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale taws• and rules and reputations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the lollowing: "I Certify that in the performance of the work for which this permit is issued. I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-coniracting signature certifies the following: "I certify that in the performance of the work for which this permit 1s issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c or all requ, inspections. Complete drawing on reverse side. C e o lo�7's f` 3 - 2�- q s Signed X Title: Data: _ FOR DEPARTMENT USE ONLY 61.2-9f 16 Application Accepted by bate Area Pit of Grout Inspection by _ Date Final Inspection by _� Date r- Additional Comments: " V`1 f] Silk 466 6781 ❑ Lodi_3&9.3621 O Manteca"823-7104 0 Tracy 8.756385 U r Applicant - Return all copies to: Environmental Health Paimil/Services 1601 E. Hazolion Ave., P.Q. Box 2009, Sik•, CA 95201 FEE 3, INFO AMOUNT DUE AMOUNT REMITTED GASH CK RECEIVED BY DATE PERMIT NO, Err 13 24IREV F rr ta.7e