82-737 - Laserfiche WebLink

Home Browse Search

�.:.. APPLICATION FOR PERMIT { y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTDN, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 Eounty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules de uia tions of the San Joaquin Local Health District, i Job Address AU. Subdivision Name 4 q i Owner's Name Address Phone ,(� n f�I oQ� Contractor's Name License No. Phone A TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F� DESTRUCTION ' PUMP INSTALLATION 'SYSTEM REPAIR--El' -'OTHER ❑- D15TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� Industrial Open Bottom E]Manteca Dia. of Well Excavation ,y � Domestic/Private 17 ❑Gravel Pack Tracy Dia. of Well Casing i Public F-1 Other Delta- ( [j Irrigation Approx. E] Eastern Type of Casing Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical Type of Grout + �J Other f � ' E Surface Seal Installed by j Repair Work Done EJ_ Type of Pump N.P. State Work Done t Well Destruction U Well Diameter Sealing Material (top 501) r Depth Filler Material' (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION — N ( o septic tank or see a it a _9 P permitted ' L.J pa p p �f public sewer is ! available within 200.feet.) Installation will serve: Residence _ Commercial _ Other _ .� Number of living units: Q Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth 5Q SEPTIC TANK Cl Type/Mfg Capacity a 0J2 No. compartments PKG. TREATMENT PLT. T e/Mf ° I� Type/Mfg 9 Capacity Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED 0 Distance to nearest: Well _ Foundation Property Line 00 ° ! SEEPAGE PITS Depth Size Number SUMPS U 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_ Nome 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 employ persons subject to workman's compensation laws of California." The applican ms' call r 11 required inspections. Complete drawing on reverse side. Signed X / Title: _ Date: F DE.PAOTMENT USE ONLY '� Application Accepted by f� Area - 2�L Stk 466-6781 Additional Comments: � Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by L✓ Date 7" Ja Tracy 835-6385'- Applicant - Return all copies to: Environmen HealthPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. - - INFO.... EH 13-24 REV. 10/82 �/� � /f� .� 10/82 500 14-26 / '