84-711 - Laserfiche WebLink

Home Browse Search

DAPPLICATION FOR PERMIT JUN 6 1984 SAN JOAQUIN LOCAL HEALTH.DISTRICT r� 1601 E. HAZELTON AVE., STOCKTON, CA_ PERMIT NO. Telephone (209) 466-6781 r SAN JOAQUIN LOCA. PERMITEXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED HEALTH DISTRI�'�", t. (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 fo"r well/pump and the Rules and Regulations f the San Joaquin Loc /I Heal District, Job Address b / 5ubdivli�s✓ion Name Owner's Name Address o2 `—�� `^ i Phone, ' Contractor's Name" License No. - - Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER F_�" :DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LIKE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .. " �.�..IN TEN DED-USE TYPE DF WELL -PROBLEM-AREA- CONSTRUC-TIONfSPECIFICATIONS - ' Industrial Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public ❑Other [] Delta Type of Casing ❑ Irrigation Approx. ❑ Eastern Specification s I]Cathodic Protection Depth ❑ Depth of Grout Seal Geophysical T Other Type of Grout Surface Seal Installed by ti Repair Work Done Type of Pump H.P. State Work Done 61 Well Destruction 01 Well Diameter Sealing Material (top 50') _ o Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (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 w SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f? t PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION Cl LEACHING LINE F-f No. & Length of lines Total length/size FILTER BED Distance"to nearest: Well Foundation `"Property"tine SEEPAGE PITS ❑ Depth Size Number SUMPS IJ 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 . ued, I shall employ persons subject to workman's compensation laws of California." 2 The applic mu 1 or u' a in a ion . omplete drawing,on reverse side J Signed X itle: / Date: ARTME T USE LY Application Accepted by e5frea" ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by , Q 1A_4L-r— Date Tracy. 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 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 -.