83-300 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT'NO. Telephone (209) 466-6781 DATE ISSUED S 3 PERMIT EXPIRES 1 YEAR FROM DATE 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 and Regulations of the San Joaquin Local galth District. Job Address ] Sub ivision Name 8 3� Owner's Name Address Phone — 7 Contractor's Name License No. C5 {_ S6 3 Phone "—2407 TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT [] DESTRUCTION [f PUMP INSTALLATION SYSTEM REPAIR OTHER ' 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 ! Industrial U Open Bottom []Manteca Dia, of Well Excavation 3; Domestic/Private ❑ Gravel Pack [f Tracy Dia, of Well Casing 17 Public Fl Other Delta Type of Casing , Ljirrigation Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical Type of Grout ED other Surface Seal Installed by Repair Work Done E) Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [j REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is \ available within 200 feet.) Installation will serve: Residence Y Commercial _ Other Number of living units: / Number of bedrooms 3 Lot sizer/ t7 Character of soil to a depth of 3 feet: Water table depth -/ o SEPTIC TANK Ej Type/Mfg if Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines 1 C! Total length/size X �<+V—. YR, ' FILTER BED Distance to nearest: Well _ Foundation 3p' Property Line SEEPAGE PITS Depth Size Number r SUMPS C1 Distance to nearest: Well FoundationProperty 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, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the followinq: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe on in such manner as to become subject to workman compensation laws of California." Contractor's h' in g or sub-contracting s' ure certifies the following: "I certify that in the performance of the work for which this permit ' ssued, I shall employ p ons subject to workman's compensation laws of California." The appli t call fo all r r d inspections. Compl a drawing on reverse side. � � Signed Title: Date: OR ARTMENJO,USE ONLY , Application Accepted byr Area � -— Stk 466-6781 Additional Comments: D Lodi 369-3621 Pit or Grout Ins>byr!!� y Date : —J�— D Manteca 823-7104 Final InspectionDate ;�`j-�S3 ❑ Tracy 835-6385 Applicant - Return all : Environmental Health ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j I FFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFa 3_ti73 �3`3av EH 13-24 REV. 10/82 10/82 500 14-26