83-698 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT C� Q 1601 E. HAZELTON AVE. STOCKTON, CA PERMIT NO. 0 3 t0 6 u Telephone (209) 466-6781 DATE ISSUED ( I 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 Health District. Job Addressa� d .�.�,. 4— Subdivision Name Owner's Name Address YIpj !&IA:,xy� -z,a,�. Phone Contractor's Name License No. t! T l Phone'3&4— _ V !b cA TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ W PUMP INSTALLATION [} SYSTEM REPAIR OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C� INTENDED USE TYPE OF WELL PROBLEM AREA _ CONSTRUCTION $PECI`FICATIONS Industrial U Open Bottom []Manteca " bia. of Well Excavation L_1 Domestic/Private ❑Gravel Pack [ Tracy , Dia. of Well Casing 17 Public ❑Other []'Delta Type of Casing Irrigation Approx. []Eastern Specifications Cathodic Protection F-1Cathodici Depth of Grout Seal ❑Geophysical -- `"Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing,;Material (top 50'J Depth Filler Material,}jBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Lf- RbPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is - available within 200 feet.) Installation will serve: Residence.- Commercial Other /y A/ Number of living units: ` Number of bedrooms " Lot size _ lle.G�.e�� Character of soil to a depth of I feet: -1� .uti{ V,C A-=-e - Water table depth EJ SEPTIC TANK ❑ Type/Mfg -tapacity 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: Total length/size FILTER BED [] Distance to nearest: Well Foupdation Property Line SEEPAGE PITS DKDepth 2 J Size Number SUMPS ❑ Distance to nearest: Well 7 Found tion Property 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 following: "I certify that in the performance of the work for which this ermit is issued, I shall not employ any person in such manner as to become subject to workmans 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 applicanust call r 11 required inspections. Complete drawing on everse side. Signed X Title: Date: K 0 PARTMENT USE ONL �� 71 466-6781 Applic •on Accepted by ^' Area E] Stk- -- Additional Comments: X Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date i- ❑ -Tracy 835-6385; - Return all co ies o: Environmental Hea h Permit/Services 1601 E. zelto Ave., P.O. Box 2009,' Stk., CA 95201 Applicant p FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERE;NOINFO F ? ,p' JJ tqLi.J O EH 13-24 REV. 10/82 10/82 500 *tl . 14-26