83-861 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 4666781 PERMIT EXPIRES i YEAR FROM DATE ISSUED PERMIT NO. �rtt DATE ISSUED I I (Complete in Triplicate) �X STING iC 7- 40¢ iLLCa/ri� 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_g� ,E, 41g �� g�Subdivision-Name Owner's Name ,RS Address j,4E Phone l&/ _ X70 License No.. Phone 9 MI Contractor's Name FAY/7 E _iK/E7Ca�- TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [j DESTRUCTION ❑ --PUMP -INSTALL-AT-ION•--Q-^—SYSTEM-REPA-1-R--A--E-.-------"""'"OTHER—E,---,- %DI.STANCE TO NEAREST: SEPTIC TANK "'- SEWER LINES DISPOSAL FLD. PROP, LINE y 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ss Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation, ❑ Domestic/Private Gravel Pack [ Tracy Dia. of Well Casing , ❑ Public ❑ Other Delta , � ❑ Type of Casing %irrigation Approx. ❑ Eastern Specifications } ❑ Cathodic Protection Depth Depth -of Grout: , 4 - ❑ GeophysicalType of Grout e, � ❑ Other `f '�� Surface Seal Installed by -F- Repair Work Done ❑ Type of;Pump H.P. State Work Done_ _ 1 Well'Destruction F-1 Wel l Diameter..._ s Sealing Material (top 50') ' Depth Filler Material (Below 50: f � TYPE OF SEPTIC WORK: . NEW INSTALLATION LVI REPAIR/ADDITION I(ND septic tank or seepage pit avaermittedithid if nublicfsewe) is / «0 Installation will 'serve: Residence M CoArcial _ Other Number of living units: _ Number of bedrooms �/ �Lot size. 9 I ' Character of soil to a depth of 3 feet: �,� W - Water table depth a< SEPTIC TANK Type/Mfg _� L _ Capacity, T �,Z ©� PMethod of Disposal No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg - -.-Capacity ..._ . SEWAGE SYSTEM t7 Distance to nearest: Wel 77C? .. Foundation �'0 Property Line_ r �© DESTRUCTION _ T` No..& Length of lines - Total length/size CJ / Z LEACHING LINE g ! FILTER BED Distance to nearest: Wel Foundation,_ Property Ling •_� ❑ F' EPAGE PITS Depth SE•� Size Numberr� SUMPS t° L1 Distance to nearest: Well �.___ Foundation % ' Property Line DISPOSAL PONDS ❑I �` '.: 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 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 foe which this in such manner as to become subject to workman§ compensation laws bf 'California." permit is issued, I shall not employ any person certifies the following: "I certify that in the performance of`the:,work`for which Contractor's hiring or sub -contracting signature bject to workman's compensation laws of California."P this permit is issued, I shall employ persons su` The applicant must c 11 fl all" require inspections. ,Complete drawing on reverse side. V Date:, Signed X Title: , 't R_ E RTME SE ONLY ❑ Stk 466-6781 Application Accepted Area � 4 ` ❑ Lodi 369-3621 Additional Comments '3 ❑ Manteca 823-7104 Pit or Grout Inspection by Date " Final Inspection by ,. Date y`2 ❑ Tracy 836-6385 Applicant - Return all copies vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t_DATE PERMIT NO. FEE ` BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 4 r_ INFO 4 r 1 I cf 6?)_1 -,qi } — 10J82 500 EH 13-24 REV. 10/82 6` !