83-884 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERM a C d ! 1 f3 Ee( 1 D SAN JOAQUIN LOCAL H74THICT 1501 E. HAZELTON AVE., ST"'AUG r, 1983 PERMIT NO. Telephone (209) 466-6181 fi [ DATE ISSUED l7 5`3 PERMIT EXPIRES 1 YEAR FROM DAT SUED {� LOCAL (Complete in Triplicate S`"c�+Lit+t,/��, N LT4� DISTi !C Application is herety made to the San Joaquin Local Health District'for a permit to construe al, or install the work herein described. This app]ication 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 .CJ S ..c4 Subdivision Name Owner's Name Ct-nac _Address Phone Contractor's Name License.No. - ► Gja. �� Phone TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT "DESTRUCTION F-1 PUMP INSTALLATION SYSTEM REPAIR OTHER Lj DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_ FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l�- Iy�dustri:a.l� U_ppen Battom� -Man,t _ of4Wel�Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy _,Dia. _ - -- - Dia. Of We'll Casirg_— - Public 11 Other ❑ Delta r Type of Casing �j irrigation Approx. Eastern _ Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal — T e f r o out Type G Other Surface Seal Installed by Repair Work Done ❑ Type of Pump °��H,P. State Work Done 0&42 ,&.a Well Destruction [—IWellDiameter Sealing Material (top 501) Depth Filler Material (Below 501) 1 i TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION Installation will serve: Residence _ Commercial _ Number of living units: Number of bedrooms _ Character of soil to a depth of I feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. U Type/Mfg SEWAGE SYSTEM Distance DESTRUCTION ❑ to nearest: Well J (No Septic tank or seepage pit permitted if public sewer is available within 200 feet.) Other Lot size Capacity _ Capacity Foundation Water table depth —_ No. Compartments _ Method of Disposal Property Line LEACHING LINE LJ No. & Length of lines Total length/size FILTER -BED �.. '. Distancelto nearest: Well Foundation Property Line W 1 00 .r" iv 9 r A SEEPAGE'PITS ❑ 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 dore 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 i permit is issued, I shall not emplby 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 j this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant �>must call for all required inspectio s. Complete drawing on reverse side. (� Signed X— /`,P" j �_�0 r r Title: Date: I},. C i R DEP Tf1ENT USE ONLY Application Accepted by Area �� Stk 465-5781 Additional Comments: LIZ Lodi 369-3621 Pit or Grout Inspection b Date ❑ Manteca 823-7104 Final Inspection by Date j Tracy $35-6385 Applicant - Return all copies to:r,Environmental Health Permit/Services 166T Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEI BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO EH 13-24 REV. 10/82 10/82 500 14-25