83-944 - Laserfiche WebLink

Home Browse Search

. 1 APPLICATION FOR PERM;` SAN JOAQCiN LOCAL HE-.LTH JiSTRICT 1601 E. HALELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 r)x DATE ISSUED JlJ t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �� — /2 -0 7 Application is hereby mad e;[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 LaEal Health District. 1n� i � Job Address� � 5- J� � Subdivision Name Owner's Name � �7� Address p on Contractor's Name [.C�c _� License No. /6 Z 31 3 Phone TYPE Of WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ } PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ / DISTANCE TO NEAREST: SEPTIC TANK /�/' SEWER LINES �/ N DISPOSAL FLD. NO W PROP. LINE Q FOUNDATION � AGRICULTURE WELL da OTHER HELL PITS/5llMP5/V a r INTENDED USE �� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �' I ❑ ec /b Industrial U Open Bottom Manta Dia. of Well Excavation Domestic/Private F!erGravel Pack Tracy Dia. of Well Casing ItD Public —1 Other ❑ Delta Type of Casing V Irrigation po Approx. Eastern Specifications Cathodic Protection I Depth F Depth of Grout Seal Geophysical p Type of Grout Other p f Surface Seal Installed by i --Repair Work--Done J Ty pe,of—Pump 1 ---H.P• f�� --State-Wor-k-Hone ^� ,rp Scaling Material (top 50') Well Destruction U We11iLDiameter 9 Depth Filler Material (Below 50') •, TYPE OF SEPTIC WORK: NEWIINSTALLATION [1 REPAIR/ADDITION U (No septic tank or seepage pit permi-tted.if public sewer is ,. available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to ar epth of 3 feet; Water table depth SEPTIC TANK E I Type/Mfg Capacity No. Compartments �PKG. TREATMENT PLT. "Type/Mfg' Capacity Method of Disposal t SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line ` DESTRUCTION C LEACHING LINE U No. & Length of lines Total length/size /A FILTER BED 'Distance'to nearest: Well Foundation Property Line SEEPAGE PITS 713Depth Size Number SUMPS �� Distancetonearest: Well Foundation Property Line DISPOSAL PONDS ED ' I hereby certify that I the prepared this application and that the work will be done in accordance with San Joaquin county 1 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 sha ll 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, F shall employ persons subject to workman's compensation laws of California." The applic mu t call$i all requir inspections. Complete drawing on reverse side. r Signed X Title: Date: • FOR DEPARTMENT USE ONLY Stk 466-6781 Application Accepted,by Area ( } I }, Lodi 369-3621 Additional Comments: f If- Date Manteca 823-7104 Pit or Grout InspectiAb ` ' Date ❑ Tracy 835-6385 Final Inspection�by Applicant - Return allopienviro men ealth Permit/Services 160 E. azel on Ave., P.O. Box 2009, 5t k., CA 95201 + I - PERMIT N0. FEE BASE $ AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATES Z Q q INFO O GLJ O ` I!� 500 EH 13-24 REV, 10/82 14-26 R