83-205 - Laserfiche WebLink

Home Browse Search

i .woe � APPLICATION FOR PERMIT La r!0 hPt SAN JOAQUIN LOCAL HEALTH DISTRICT r � k/ 4 1601 E. HAZELTON AVE., STDCKTON, CA PERMIT NO. Z� Telep""hone (209) 466w6781 . i� DATE ISSUED r l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) , v- Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein F E described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Healt-b DDiissttriicetc{1 //�1 Jab Address 3aa a � & Suivid soon Name�Q, c Owner's Name Address S/¢ts2E __ Phone Contractor's Name ELt1fLF,, We42> License N.:- ,7� y7L� Phone y TYPE OF WELL/PUMP WORK: A NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF-WELL PROBLEM'AREA CONSTRUCTION SPECIFICATIONS � ❑ Industrial L Open Bottdm' Manteca , Dia. of Well Excavation Domestic/Private ❑Gravel Pack Tracy ` Dia:' of Well Casing Public ❑ Other R ❑ Delta �h _Type of Casing Irrigation Approx. []Eastern Specifications Cathodic Protection Depth f ❑ } Depth of Grout Seal 1-1Geophysical y i Type of Grout ❑Other } ,Y Surface Seal Installed by e Repair Work Done � Type of Pump H.P. StaterWorttk Done Well Destruction ❑ Well Diameter s Sealing Material, (top 50') Depth + Filler Material (Below 50')` TYPE OF SEPTIC WORK: NEW INSTALL TI J REPAIR/ADDITION L (No septictank•or seepage pit permitted if public sewer is. F. * available within 200 feet.). ` Installation will serve: •Resider Py—, Commercial Other C' Number of Living units_ Numberof bedrooms K Lot size y AG Character.of soil to a depth"ofA 3 feet: dI-A y _ Water table depth SEPTIC TANK Type/Mfg /akaf.L— � Capacity'— No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg '�' __ Capacity; Method of Disposal 1 SEWAGE SYSTEM Distance to nearest Well _ Foundation i7-e Property Line 7 DESTRUCTION a r i LEACHING LINE No. & Length of,,lines Z ` g S� Total length/size "FILT'ER BED ❑ Distance}to nearest: »Well; � O�- Foundation �a , Property Line /p SEEPAGE PITS Depth, .iAS-1 Size \4 .3 i" Number Z P SUMPS ` #� ❑' 1 Distance to nearest: Well Foundation /a-- Property Line i iDISPOSAL PONDS- 'A", I hereby certify that I have prepared Chis application and'�that'lthe work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the.,San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person irr,such manner as to become subject to workman§ compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:. "I 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 applicant must call for all required i spections. Completeidrawing on reverse side.__„ k Hate: F Signed X Title: �RTM ENTA E4 LY i4� Application Accepted by ��/V 4Area Stk 466-6781 ;' t-- Lodi 369-3621 Additional Comments: ❑ Pit or Grout Inspection by Date yi ❑ Manteca 823-7104 Final Inspection by Oate7 � Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT OUE AMOUNT REMITTED RECEIVED BY' DATE PERMIT NO, i INFO t EH 13-24 REV. 10/82 10/82 500 14-25