83-941 - Laserfiche WebLink

Home Browse Search

•_A� APPLICATION FOR PERMIT �a SAN JOAQUiN. LOCAL HEALTH DISTRICT 1601 E. HAZELTDN AVE., STOCKTON, CA PERMIT N0. 3 Telephone (209) 466-6781 44�J2DATE ISSUED 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 Regulaatiors of the San Joaquin .Local health Distric Job Address Q { tilrI-)IL Cf �S1u ��'me GLI� C� t� Owner's Name G r_ C n y- Address PU Phone 13-3 7 Contractor's Name Ey-taeS ,S-f t ! R.W � License No,'3�y Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPOAEEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM RE'PA$R ❑ OTHER Lj DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WCL"L'OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA t CONSTRUCTION SPECIFICATIONS � ' Industria] ❑Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing Public Other Delta � -yo''w - ❑. U ❑ � �Type�of�Casing Irrigation Approx. ❑ Eastern ` Specifications Cathodic Protection Depth ❑ Depth of Grout Seal ❑Geophysical Type of Grout '4 ❑Other ,_, Surface Seal Instal lied by Repair Work Done Type of Pump H.P. State Work Done -Y p l Well Destruction ❑ Well Diameter Sealing Material (top 50') C 01 Depth Filler Material {Below 50')+w- �. ,.rw=.. " } TYPE OF SEPTIC WORK: NEW INSTALLATfON'L�REPA-IR/ADDITION tL (No septic tank o seepage;,pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other$ Number of living units: Number of;bedrooms La`s`i'ze /C Gr " •� �� aI! ° " Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK Type/Mfg Capacity �/P No Compartments Y k PKG. TREATMENT PLT. ❑ Type/Mfg I _ k r Capacity f- Method�of Dispos al SEWAGESSYSTEMON ❑ Distance to.near b6' eq _T Foundations PropertyLineY � _ A� Y LEACHING LINE No. &Length of lines' Total length/SI f FILTER BED Distance to nearest: Well a- ""?"`"r Foundation '� lProperty Line y SEEPAGE PITS ❑ Depth 'Size Number Y , SUMPS �_r�Distance to'nearest; Well Fou n at'or %O_e aF, Prop'erty Line - �.-- f DISPOSAL PONDS ❑ r s #( Rr t I hereby certify that I have prepared this application and that the:'work will be done infaccordarce with San Joaquin county ordinances, state laws, and rules'and regulations of the San Joaquiih4Local Health Dittri'ct. 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 torbecome subject;to,workman s compensation laws of California.” Contractor's hiring or sub-contracting signature certifies the fol}'owing: "I certify that in the performance of the work for which } this permit is issued, I shall employ Personslsubject to workman's compensation laws of California. +pIiThe applican ust call f all equired inspections. Complete drawing on + ererseys-i e. I Title:. . " Date: Signed x - �:�. DEPARTMENNl15E LY _ SII b ' Rppl tion Accepted by Area i�y. ❑ Stk 466-5781 Lodi 369-3621 Additional Comments: k Pit or Grout Inspection by Date ❑ Manteca 823-7104 r Final Inspection by Date , ❑ Tracy 835-6385 Applicant - Return all copies to: .Environmental allth Permit/Services 1601 E. Hazelton Ave.; P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ' PERMIT NO. INFO t �• 10/82 500 EH 13-24 REV. 10/82 14-26