86-1509 - Laserfiche WebLink

Home Browse Search

µ APPLICATION' FOR PERMIT SAN JOAQUIN,;LOCAL HEALTH- DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6181 - DATE ISSUED .. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) >t. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein 1` described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump I' and the Rules and .Regulations.of the San Joaquin Local Health District. Job Address7 b 7%= (vision Name Owner's Name fAddrfss G Phone Contractor's Name �, %�uG L.CON., License No. �" ,� Phone ,. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ + 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 s• ' Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation °� k ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ### Public Other Delta A ❑ ❑ ❑ Type of Casing Irrigation Approx. []Eastern Specifications 1Cathodic Protection Depth r ❑ ecDepth of Grout Seal ❑Geophysical R. 179pe of Grout ❑Other5urfac-Seal Installed by 4 .' i Repair Work Done ❑ Type of Pump H.P. ,- State Work Done, Well Destruction ❑ .Well Diameter Seal ing'Mate al (top 50') _ Depth �;fille Material (:Below 50' TYPE OFTSEPTIC WORK:- NEW INSTALLATION REPAIR%ADDITION ❑ (No septic tank or seepage pit"permifted.,if�public public- sewer '9 T '! available witljtin 200 feet.} - V 14 4 Installation will serve: Reidence Commercial _ Other Number of living units: Number of bedrooms Aot size R d u 1 Character of soil to'a 'depth.Af 3 feet:r. Water table depth { ' f r. "' /M1.x^'k Ci If No. Cam atments ! r+r € SEPTIC TANK.1• _- - TY Pe/Mfg ..= ��el`�i - — p �Y t pi• `J 4 PKG.�TREATMENT PLT. E] Metho Type/Mfg "`- Capacity,--. , d of Disposal F" M SEWAGE SYSTEM Distance to nearest: Well //�yaP�rFoundation- �T Property Line [p ' DESTRUCTION ❑ ' r', �"` r E # LEACHING LINE No. 6 Length;of lines Total length/sizJ i FILTER BED [] -bisiance.to nearest: Well Foundation'y y Property Line € SEEPAGE PITS I V_'Depth_ /. "T 5ize Nummbber � SUMPS U Distance to neareste: Well Foundation- tis �`�roperty LinetS DISPOSAL PONDS ❑ y! 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 Lqcal 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 1s 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 r this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must c 11 f all uired inspections. Complete drawing on reverse side. / Signed X Title: ' Date: • T�USE ONLY I j Appl�catian Accepted by `Area - F ❑ Stk F 466-6781 i Additional -Grentsi ' ❑ Lodi 369-3621 Pit or Grout In by 5 -' Date ❑ Manteca 823-7104 1 Final Inspection by Date ❑ Tracy 835-6365' Applicant - Return all copies to: Environmen Health' Permit/Services 1601 E..Hazelton eve., P.O. Box 2009, Stk., CA 95201 'FEE" "BASE "" —AMOUNT—DUE—7"'AMOUNT"REMITTED `""RECEIVED"8Y "` DATE N0: k INFO 4 „� EH'13-24 REV. 10/82 10/82 500 14-26