83-1093 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERM;T SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781' DATE ISSUEDtiJ 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 1662 for well/pump and the Rules and Regulations of the Joaquin Local Health District. Job Address �� 1�. Subdivision Name Owner's Name Address "Vle � ,c Phone Contractor's Name License No. 327 ZZIo Phone Od 1 TYPE OF WELL/PUMP WORK: _ NEW WELL ❑f WELL-"REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION❑ SYSTEM REPAIRr"""' ❑ OTHERY❑""""�"""""r DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial F-1 Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private t ❑ ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public L Other ❑ Delta Type of Casing V Irrigation Approx. ❑ Eastern ' Depth Specifications e ❑ Cathodic Protection p Depth of Grout Seal ❑Geophysical �. , Type of,Grout Other Surface Seal -Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material`(top 50') _ O Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No'septic tank or seepage pit permittedifpublic sewer is r available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms j Lot size Character:of soil to a depth of.3.feet:� �/ � -4 Water table depth n r SEPTIC TANK - "� �'❑- �-Type/Mfg. w ��. ---'—Capacity �_ ._-,�No.. Compartments PKG. TREATMENT PLT. E] Type/Mfg� Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation ti Property LineI DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines AL,0- ' Totallength/size FILTER BED ❑ Distance to nearest: Well �' Foundation -_ roperty",D ne SEEPAGE PITS Depth Sizey r Number SUMPS ❑ Distance to nearest: WellFoundation•; (?, Property Line is DISPOSAL PONDS ❑ ^• 7— \,M, 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 for whidh'this, permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California:'!- Contractor's hiring lo`r 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 mus call for all re i d inspections. Completedr ing or reverse side. 4 Signed X Title: f-rLA—, �Date: / —7--7 '9J 1 FOR DE RTMENT USE ONLY Application Accepted by Area CA- ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection } 4. Date y� ; ❑ Manteca 823-7104 Final Inspection by Date E�e�c1� l�� ❑ Tracy 835-6385 Applicant - Return all copi s to: Env;_onmental Health Permit/Services 1601601 E. azelton Ave., P.O. Box 2009, Stk., CA 45201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV, 10/82 10/82 500 14-26