83-747 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR.PERMiT k SAN JOAQUih' LOCAL HEALTH DISTRICT 1661 E. HAZELTON AVE., STOCKTON, CA PERh1IT NO. 33- �` 7 Telephone (209) 466-6781 -Z.� PERMIT EXPIRES 1 YEAR FROM DATE DATE ISSUED 3 ISSUED y (Complete in Triplicate) ' Application is hereby made to the 5an•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 and the Rules and pRegulations of the San JoaquinLocal �Health District, Job Address / /�i n� -!?7-1ZAj,�y ]C. S bdivision Name fOwner's Name Address E, Phone :3 6 rf—o Contractor's Name License No./C).-3 7 3 Phone ::5r- TYPE :5rTYPE OF WELL/PUMP WORK: 'NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION j SYSTEM REPAIR U OTHER U i 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 f1J Industrial F-1 Open Bottom Manteca Dia, of Well Excavation Domestic/Private F-1 Gravel Pack Tracy = w.:'Dia,. of Well Casing ❑ Public. ❑Other ❑ Delta Type of Cha ing� V Irrigation Approx. ❑ Eastern Specifications ElCathodic Protection Depth f Depth of Grout Seal ❑Geophysical Type of, Grout ❑Other p Surface Seal Installed by. n Repair Work Done F%?- Type of PumpH.P. J State Work Done�IA4 [ -« -Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50')' TYPE OF SEPTIC-•WORK: NEW INSTALLATIDN ❑ REPRIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 4 available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. F-1 Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ I LEACHING'LINE ❑ No, & Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPSU Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 7 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 became 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 laws of California." The applican ustall for a required i pections, ample rowing on reverse side. -0 Signed Xtle: Date: d F EP TM ENT USE NLY 7�y� Application Accepted by-7Area Stk 466-6781 I Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date L J Manteca 823-1104 I Final Inspection by �_ Date � - � Tracy 835-6385 Applicant - Return all copies to: . Environmental alth Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 F FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE a PERMIT. NO. INFO qS `711!n�1' 3 1 EH 13-24 RFV. 10/82 10/82 500 14-26