83-1085 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT T3— 1 O � 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. O Telephone (209) 466-6781 Q� 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 and Regulations of the San Joaquin Local Health District. Job Address_ 75a U< Y&1-' T7"Ni=-,e R- Subdivision Name Owner's Name Address vZ1 fil�/L�6 � Phone g�/- LQ �?/7� - Contractor's Name icense No. 9� Phone TYPE OF WELL/PUMP WORK: NEW WELL SC WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �4 T SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,yi �; k INTENDED USE TYPE OF WELL -PROBLEM AREA f CONSTRUCTION SPECIFICATIONS {� Industrial LJ Open Bottom []Manteca Dia. of Well Excavation mestic/Private 'Gravel Pack ❑ Tracy Dia. of Well Casing rpublic Ot r ,» Delta F ❑ iy O - ^ (� _� Type of Casing r _ r irrigation A rox. Eastern- rr LJ g RP fi r�Specifications ,r 71 Cathodic Protection Oepth _ �.\ t .� ❑ *� Depth of Grout Seal `L/' '3'. "x, �rtrt�� ❑Geophysical Type of Grout 17Ale-XE TYE= ❑Other Surface Seal Installed by PAN= DW144 } _ -� L _ N Repair Work Done Type Type of.Pump f�8 - h.P. �� State Work Done Well Destruction U Well Diameter Sealing Material (top 501) Depth FiI ler Material r,(Below 50'), -� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (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 I f Character of soil to a depth of 3 feet: =� Water;tabl'e-depth f M SEPTIC TANK ❑ Type/Mfg Capacity L " _ o.: Compartments let PKG. TREATMENT PLT. ❑ Type/Mfg -Capacity, Method"of Disposal V _. ) SEWAGE SYSTEM Distance to nearest: Well Foundation-."" � Property'Line # DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Y Total length/sjzey FILTER BED ❑ Distance to nearest: Well Foundation_4- - Property•L-ine'+, SEEPAGE PITS ❑j Depth Size4 a•. `Number i S I SUMPS Distance to nearest: Well Foundation Property Line . s DISPOSAL PONDS ❑1 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 workmanks compensation laws of California." o 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 applicant mit ca ] all ed Inspections. Complete draping t- Dater Signed X . 1Zitie: P FO ARTMENT USE ONLY Application Accepted by - 'Area '(7 "— -"466=6781 Additional Comments. Lo4i 369-3621 Pit or Grout Inspection by 1 Date ► ❑ MaAteca 823-7104 Final Inspection by �,; . _ ... - �� ke-. W-"e''. q[yt�y 835-6385 f _ � � 0 . . Applicant - ReturnIf all copies'to: Environmental Health1 PeTA�tfirServices 1601 E. Hazelton Ave., P.O. ga% 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED. BY DATE PERMIT NO. INFO 70'93 73 An 3 cr 10/82 500 �L EH 13-24 REV. 10/82 14-26