83-56 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 ' Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED HATE ISSUED _441-3 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 /Q ee_'c L&P subdivision Name Owner's Name Address Phone Contractor's NamesQ/ils -- License No. SIi( Phone ti TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER [:] { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom []Manteca Dia. of Well Excavation Domestic/Private Gravel Pack 0 Tracy Dia. of Well Casing iF Public E]Other ❑ Delta Irrigation Type of Casing Approx. � Eastern ❑Cathodic Protection Depth Specifications EJ-Geophysical Depth of Grout Seal 1__J Other Type of Grout Surface Seal Installed by k Repair Work Done.G Type of Pump H.P. State Work Done Well Destruction Well Diameter 1 U Sealing Material {top 50 ) (y,1 Depth Filler Material (Below 50') VN TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION A (No septic tank or seepage pit permitted if public sewer is Installation will serve: /Residence Commercial _ Other available within 200 feet.} Number of living units: / Number of bedrooms _ Lot size Character of soil to a depth of 3 feet: Water table depth Vj O � SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE U No. & Length of lines Total length/size FILTER BED I Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth,_ . �� Size B Number SUMPS U Distance to nearest: Well oundatigncam. Property Line DISPOSAL PONDS E) r 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 which 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 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 Taws of California." The applican cal for al]� quire ions. Complete drawin on terse s' e. 7 Signed r Title: Date: TMENT USE ONLY Application Accepted byF R DEPe. ,20.-23 Area '/, �5tk 466-6781 Additional Comments; Lodi 369-3621 �I Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by rJtt Date a. Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16 1 E�H-aze�lton Ave., P.O. Box 2009, Stk., CA 95201 1 T FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Y.3 EH 13-24 REV. 10/82 I4-26 10/82 500 .