83-697 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT "� 1601 E. HAZEL-TON AVE., STOCKTON, CA PERMIT NO. �J (p L / Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 7 X y l (Complete in Triplicate) Application is hereby made to the San'Joaquin Local Health District for a permit to,construct and/or install the work herein 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 Health District. Job Address 1-z�Q O Al, eX(. x -_ Subdivision Name I-,OD 1 - Owner's Name OUA?, i49L 7T(L Address _ C 7!?O �, L-7L/t-y �� phone �69-C�F9�5 Contractor's Name GO(-W[WC PLgle, License No. QPhone ZzY TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U 4� PUMP INSTALLATION ❑ SYSTEM REPAIRIS OTHER U DISTANCE TO NEAREST: SEPTIC TANK 2,00 SEWER LINES 2 Z-0 DISPOSAL FLD. /DO PROP. LINE 36 1 t FOUNDATION `LQ AGRICULTURE WELL OTHER WELL (J PITS/SUMPS , A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Jindustrial U Open Bottom, Manteca Dia. of Well Excavation U Domestic/Private 'F-] Gravel Pack [] Tracy Dia, of Well Casing Public , Other,, ` Delta Type of Casing Irrigation *-^- ' ' Approx-' Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal 1-1 Geophysical Type of Grout D Other - ( Surface Seal .Installed by Repair Work Done Type of Pump TUI�jIN. H.P. 7y2-- State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') {f1 j: TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION }JJ (No septic tank or seepage pit permitted if public sewer is D available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soilto a depth of 3 �feet-:' Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG, TREATMENT PET. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM -' Distance to.'nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines- Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Fi Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application andthat tYi 7ork'wi1T`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, .1 shall not employ any person in such manner as to become subject to workman`§ compensation laws of California." Contractor's hiring or sub-contracting signature certifies th'e fClloWi'ng:-"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 applican must call for 11 re inspections. Complete dra 'ng on reverse side. Signed X ,u., fTitle: Date: Z /k3 FOR DEPARTMENT USE ONLY Application Accepted by Area St-k 466-6781 Additional Comments: Lodi 369-3621 i Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by nJJA9AqA Date L Tracy 835-6385 Applicant - Return all copies to. Environmental Health Permit/Services 1O E. H zelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT- REMITTED RECEIVED BY DATE pp PER/MITT NO. INFO C� j O 3 fp I EH 13-24- REV, 10/82 10/82 500 14-26