83-1208 - Laserfiche WebLink

Home Browse Search

t. Y f; APPLICATION FOR PERMIT SAN JOAQUIT! LOCAL HFALT} DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 0 Telephone (209) 466-6781 i PERMIT EXPIRES 1-YEAR FROM GATE ISSUED DATE I SSUED (Complete in Triplicate) i f Application is hereby made to the San Joaquir 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 r. and the Rules and Regulations of t e San Joaquin Local Health District. Job Address 5 9 t n JNZ'o ^ R—b Subdivision Name qL Owner's Name 'T h4Ip)S p N Address Phone Contractor's NameII , License No. Phone .,1 tkA or el I TYPE OF WELL/L4P � �P NEL! WELL WELL REPLACEMENT DESTRUCTION P'MP INSTALLATION SYSTEM REPAIR. OTHER DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,E. INTENDED',TUSETY?E OF WELL f,PROBLEM-AREA CONSTRUCTION SPECIFICATIONS ?' �❑ Industrial � u Open Bottom E Manteca Dia. of Well Excavation a I �y I Lf Domestic/Private ;,Q Gravel Pack Tracy Dia. of Well Casing Public I.[I Other [] Delta �r LjIrrigation Approx, Eastern � De th �~ Specifications y Cathodic Protection P ,,:, Geophysical Depth of Grout III,Seal I Cs Eflother Type of Grout Surface Seal Inst $led by Repair Work Dane - Type olf Pimp S. H,P, t State Work Done Well Destruction U Well Diameter I C Sealing Material (tap 50') Depth,11 Filler Material Below k501)f TYPE OF SEPTIC WORK: NEW INSTALLATION ISI REPAIR/ADDITION U+ (No septic tank or seepage pit permitted if public sewer•is I :.r_ available within 200 feet.) Installation will server Residence _ Comme-rcial Other Number of living units:,l Number of bedrooms Lot size Character of soil to a'depth of 3 feet: - Water table depth 10) SEPTIC TANK �j Type/h1fg r�,r� Ae�r o nl Capacity A No. Compartments PKG. TREATMENT PLT. Type/Mfg 4 _ Capacity j Method of Disposal [ SIL.:.- �. SEWAGE SYSTEM D stancegf'o nearest:'r Well Fourdation Property Line DESTRUCTION D I� LEACHING LINE [J *N18,. & Length of lines Total length/size FILTER BED D stance to nearest: Well Foundation Property Line SEEPAGE PITS Lj Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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, andi1rules 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 ^nlot employ any person in such manner as to became subject to workmant 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 laws of California." The applic must callo�Iall required inspections. Complete drawing or reverse side. �y I+ Signe .,--„T_itle 2-0..NT/! Date:aC f k3 IFO D K TM N USIY.,ONLY _ � Application Accepted' by Area3 Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-7104 Final Ins ection b p by ' Date L Tracy 835-6385 Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. HazeltolAve., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOJNT DUE AMOUNT REMITTED RECEIVED BY RATE PERMIT NO. e INFO 4 EH 13-24 REV. 10/82 10/82 500 14-26 �