83-196 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT . r SAN JOAQUIN LOCAL HEALT4i DISTRICT 1601 E. hAZELTON AVE., STOCKTON, CA PERMIT NO. - Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED {Complete in Triplicate} it Application is her, made to the San de iJoaquin Local w Health ith District for a Perdinan�ecNoSt549tfor dsewage sorlNothrein 1862rforewelllpump described. This application is and the Rules and.Regulations of the San Joaquin Local Health District. ,(herok. ee Road Subdivision Name T Phone Jab Address +° P-en 3 r) aIYin `101t 1KI• Owner's Name 2 V 1 C1 c�u!;�1n Address 2 PhoneEQ 35r Contractor's Name Crutol-11--8�d a st°License No. WELL REPLACEMENT ❑ DESTRUCTION ❑ V`' TYPE OF WELL/PUMP WORK: NEW WELL Q SYSTEM REPAIR ❑ OTHER ❑ 7 PUMP INSTALLATION ❑ 10 none DISPOSAL FLO. none PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES PITS/SUMPS -S)t FOUNDATION AGRICULTURE WELL �•1 OTHER WELL �� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Bottom �]Manteca Dia. of Well Excavation idus ntrial Open Dia. of Well Casing ❑ Domestic/Private ❑Gravel Pack ❑ Tracy � .1-.1111 ❑ ta ❑ Public ❑Other t = DelType of Casing Approx. Eastern Spifications A Irrigation pp ❑ k - ' Cathodic Protection Depth Depth-of Grout Seal ❑ -} ❑Geophysical ` Type of Grout- ti Other Surface Seal Instald by M.P. ` State Work Done Repair Work Done ❑ Type of Pump '� -_ ,�• Well Destruction ❑ Well Diameter _�� Sealing-,Material (top 501) Depth Filler Material (Below 5O') -C REPAIR/ADDITION, ❑ (No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION available within 260-feet,)Commercial VI-Other Installation will serve: Residence Number of living units: Number of bedrooms Lot size �_•�_ "� �- -,,,; _ Water"table depth j Character of soil to a depth of 3 feet; ; li Capacity:' Zp No. Compartments �tw O SEPTIC TANK- [� Type/Mfg O Y1C ret e - ------ Ca¢acity Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Line Property ' [ SEWAGE SYSTEM .D1s`tance to nearest: Well 'Foundation x_ DESTRUCTION S Total lengtth'Nize r+ LEACHING LINE 0674 Length of lines One Foundation � Property.�Line FILTER BED ❑S'71stan a to nearest: Well r �b Number- 011e SEEPAGE PITS ! ` M Depth 2 Size z s Foundation Property:Line SUMPS ❑ Drstance to nearest: Well A r k t +, DISPOSAL PONDS ❑ - _ ^lication and that the work will be done in accordance with San•'3oagdin couny; } tl I hereby certify that,/I have prepared"tKi"s'app - "I certify that in the performance of the work for'which this ordinances,,state laws, and rules and"regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: permit is issued, I all not employ any�?erson in such manner as to become subject to tify at in thi pepenaation'Daws a fornwhic Contractor's hit or sub-contracti signature�certitoes the n6 sl�ompensationrlaws ofaCaliforniyerformance pf the woik =ork which '~ subject .. this permit i ued, I shall pets `,� i ec ions. Complete drawing on.reverse side. The applic t ust call f req treasurer Date: L !� Title: R p T 7 USE ONLY �, ��i ( Stk 466-67811 .. Area -. ' Application ❑ Lodi 369-3621 Additional Comments: Date`_'_ ��L� Manteca 823-7104 ;s l Pit or Grout Inspection by7�� L�raey---a35-6385%' Date �/ Cp 95201 Final Inspection by / t Applicant - Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton�Aw''e.•,}P.O. Box 2009, Stk�•�' s.r--T g DATE' PERMIT N0. 3" AMOUNT REMITTED RECEIVED BY EFEE BASE AMOUNT DUE � � �� $�,�i{�•J � , �� J�� ''FY6/82 50 y. EH 13-24 REV, 10/82 14-26 „