87-1713 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQLI' LOCA:. HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE 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 an Re gllations of the San Joaquin Local Health District. Job Address �11 AuSTI.N Subdivision Name Owner's Name (aQIC? �e�i.VcrTl Address me- Phone Contractor's Name �J j/Y� CA%ZIsI L1' License No. 21y3 jg Phone �$ `/ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLT:S/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE IONS Industrial [D Open Bottom F-1 Manteca Dia. o 1 Excavation U Domestic/Private Gravel Pack —ITa. of Well Casing Public Other Delta Type of Casing �j Irrigation Approx. Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done [j Type of Pump H.P. State Work Done Well Destruction F-1- Well D' ter Sealing Material (top 50') — Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION [] (No septic tank or seepage pit permitted ifailable public fublicsewe)) is Installation will serve: Residence Commercial _ Other Number of living units: I Number of bedrooms Z Lot size aCQe) S^tiAV Water table depth Character of soil to a depth of 3 feet: n SEPTIC TANK M/ Type/Mfg �'_Gt1'T Capacity �2 0� No. Compartments f� PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION 1 9(3 LEACHING LINE ✓� No. & Length of lines 2- 7 t?� Total length/size '-/I 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall emplpersons subject to workman's compensation laws of California." The applicant m _call for �all � r�e red inspections. Complete drawing on reverse side. Date: Signed X Title: 0wN41— FOR TMENT USE ONLY Stk 466-6781 Application Accepted by /e!_f Area (vlVV Lodi 369-3621 Additional Comments: Date 823-7104 Pit or Grout Inspection by Date Final Inspection by Date �— �. i�— Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 PERMIT NO. FEE BASE AMOUNT- DUE AMOUNT REMITTED .RECEIVED By DATE Q l?/ INFO 4 foo w '��Dr�$ --/+'7 ` 77` f 10/82 500 EH 13-24 REV.. 10/82 14-26