83-1231 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL 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'con struct and/or install the work'herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or ND, 1862 for well/pump and the Rules and Regulations of the.San Joaquin Local Health District, Job Address 3 BeW AWR ____ _ Subdivision Name Owner's Name "G+pS Address 7&Ac_ - Phone Contractor's Name � �.�� f=�.�GG�2_ License No.. rJ � Phone _ /J TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION ❑ , PUMP INSTALLATION SYSTEM,-REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE W , FOUNDATION AGRICULTURE WELL OTHER WELL ? PITS/SUMPS INTENDED ISE TYPE OF WELL PROBLEM AREA CONSTRUCT)[ON SPECIFICATIONS 4 industrial I ❑ Open Bottom Manteca Dia. of"Well Excavation �J ❑ Domestic/Private Gravel Pack Tracy Dia, of Well Casing k Public �j Other Delta l Type of Casing V Irrigation Approx. Eastern Depth Specifications Cathodic Protection Depth of Grout Seal Geophysical Type of Grout U Other Surface'Sea.l (Installed by Repair Work Don ❑ Type of Pumps H P. StaterWork�Done Well Destruction ❑ Well DiameterSealing Material(top 50') Depth Filler Material (Below 50') ' { TYPE OF".S.EPTIC+ r WORK:' NEW INSTALLATION- -REPAIR/ADDITION ,U (No septic.tank or seepage pit,;permitted if public sewer is . 'moi `-- qt r j avv Vi'lable"wi tYiin-200-feet-)T lnstallatiorn will serve:- "Residence L Commercial Other Number of 1 iIving' units: NumG�P of be8ti aoms _`"� ""L`ot'size �.1 �,34;-7 Character of, soil to a depth of,3 feet: _ Dc � a SEPTIC TANK Type/Mfg Q ,[,_ ' _ " �� ,_ Capacity ,✓/r�rJ No:Compartments —r— _ - - PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposa=l $ # tt S 1, . - SEWAGE SYSTEM! Distance to nearest: Well Foundation �_ Property Line, DESTRUCTION ❑ 1 i ` a �_. Fr' � LEACHING LINE ` No. .& Length o -iin'e's�`"" "_" ��rr - _ Total length/size Q FILTER BEfl' = Distance to nearest: Well Foundation l Property Line �►' 1. SEEPAGE PITS ' ❑ Depth^ Size Number v SUMPS Distance to nearest: Well Foundation _ Property Line a 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. I I "1.` 1k 4: Home owner or#licensed agent's signature certifies the following: "I certify that in the performance of'the work for which thi permit is issued, I shall not employ any person in such manner as to become subject to"workman t compensation 1pws of Cal iforni Contractor's hiring or sub-contracting signature certifies the'followin§: "I certify that in the performance of the work for wl ich this permit is issued, I shall employ persons subject to.workman's compensation laws oft California." # The applicant must call f a eq d inspections. " Complete drawing on revers6-sidlk c� R- Signed X ?. s Title: Date: / F/ FOR DEP R ENT USE ONLY 77 { ❑ St k' 466-6781 Application Accepted by ' c. Area I- ; k 'Additio'nal Comments: i Lodi 369-3621 Pit or1Graut Inspection by Date U Manteca 823-7104 � Final Inspection bye'" Date I¢ Tracy 835-6385 ApplicahtV,Return all copies to: Environmegul Health Permit/Services 1601 EHazelton Ave., P.O. Box 2009, Stk„ CA 95201 - .•- -FEEY' J BASE—--AMOUNT- DUE—, -'•-"AM0UNT-REM'1iTE3 - .;REGE-LVED-'BY'� �--.••---DA"TE-.�-•.--' -.-PERM"I-T_NO.r , EH 13-24 REV. 10/82 )A\/ v 10/82 500 i 14-26