83-736 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMiT ` SAN JOAQLiN LOCAL HEALTH 'DISTRICT 13-73 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 2''pati . Telephone (209) 466-6781 DATE ISSUED `7 1,16[�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 Health District. Job Address 3 Subdivision Name AA C A/2 Owner's Name Address IZMVVIAIPhone C1 3�1 Contractor's Name �R � � �f�fb o License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATI SYSTEM REPAIR OTHER / U � i DISTANCE TO NEAREST: SEPTIC TANK /I 1 SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL �O / PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� /I `1 IJ I trial U Ope ottom � Manteca Dia. of Well Excavation Id omestic/Private ravel Pack [� Tracy Dia. of Well Casing tr Public �Other Delta id 12 S� Al-k - Type of Casing F71lrrigation Approx. (] Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal ❑ Geophysical ,/N1z.//7 LJ Other Type of Grout _S / ! Surface Seal Installed by 44 A Repair Work Done EJ Type of Pump 941 H.P. State Work Done C Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') / TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK F-1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [-j 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 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 permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation laws of California." Contractor's hiring or gab%contracting signature certifies the following: "I certify that in the performance of the work for which this permit 'ss 1 loy p so s subject to workman's compensation laws of California." The appli s al 11 r i in ections. Complete d t)n n I Signed X Title: v Date r FAR ARTMENT USE ONLY Application Accepted by Area Stk 46 - Additional Comments: V E Lodi 369- 1 Z Pit or Grout Inspection by Date ? L�- e ti D Manteca 823-7104 Final Inspection by ,. Date .� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16 E'� Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26