83-477 - Laserfiche WebLink

Home Browse Search

r, ,4. APPLICATION FORfERMIT r_ SAN JOAQJiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. 13 -L(7 7 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM GATE 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. 1862 for well/pump and the Rules an Regulatirs of the San Joaquin Local Health District. Job Address . Subdivision Name _ Owner's Name Address Phone _ Contractor's.Ni/me-. t L Llicense No. a> �_ mm Phone V V TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 1 PUMP INSTALLATION ❑ SYSTEM REPAIR e 07HERc" U I DISTANCE TO NEAREST: SEPTICS TANK SEWER LINES "'"'T moi+} bISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS^ �} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ( Industrial U Open Bottom (] Manteca Dia. of Well Excavation Domestic/Private w_�LJ �Gravel Pack n Tracy Dia, of Well Casing I7 Public + F-IOther Delta lrri ation Type of Casing L._j� 9 Approx. � Eastern Q`Oaahodic Protection Depth Specifications �. Depth of Grout Seal �!GeoQhyslcaI �. _;71• Type of Grout LJ Other i Surface Seal Installed by 10 tepair Work Done Type of Pump H.P, State Work Dane Well Destruction U Well Diameter Sealing Material (top 50') _ ,r Depth Filler Material (Below 50'.) TYPE OF SEPTIC WORK;, NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence A Commercial _ Other Number of living units: _� Number of bedrooms _ Lot size—" ; Character of soil to a depth of 3 feet: _ �Q�i�_ !_ _ a� Water table depth r SEPTIC TANKType/Mfg Ca acit t, (No. x Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM p _Distance-to-nearest: Well Foundation Property Line DESTRUCTION Qw ! _ f 1 r4. t LEACHING LINE [J No. & Length of lines ;Total length/size FILTER BED E_1';111 Distance'to nearest: Well Foundation's PropertysLine SEEPAGE PITS Depth -- i Size2 (Number 3 SUMPS iU Distance to nearest: Well 1j 571 Foundation -' Property'Line DISPOSAL PONDS 1Ci ' t j 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 ploy persons subject to workman's compensation laws of California." The app ' u t cal f. 11 eq_u�red insp ctions, Complete cawing r e side Sig Title: Date: V �� A. MENT E ONLY Application Accepted Area -� [] Stk 46fi-6781 Additional Comments-.(' Lodi 369-3621 Pit or Grout Insp ction by Date Manteca 823-7104 Final Inspection by Date `163 Tracy 835-6385 s Applicant - Return all copie'sEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE _j AMOUNT REMITTED RECEIVED BY gDATE �{ �J PERMIT NO. INFO EH 13-24 REV. 10/82 t """ "" """ ";' (}r� y � 10182 500 j 14-26 1