82-651 - Laserfiche WebLink

Home Browse Search

Att. IP4 T(J4 APPLICA-1-166N �FOk`Pf'I ITS SAN JOAQUIN LOCAL HEALTH DI31`RICT 1601 E. HAZELTON AVE., STOCKTON. CA PERMIT-NO. Telephone (209) 466-6781. �A PERMIT EXPIRE5,,I4AR:FROM'DATEISSUED.,,.,; DATE ISSUED (Complete-in:-Triplicate) ij,,.': -1 L��,? tiT n Application is hereby made to the San Joaquin Local Health District for a permit to construct' . and/or install lihe"Wr W' Ardescribed. (This application As,madeAn _compliance 1 , , - compliance wi# .San Joaquin.County Ordinance:No.-54916r 'seWige or!Nor 1862 fdr' wel-1/pur9p4hd'the Rulei and' Re'ulat109s pf'theSanJoaquin Local H6a)th District,. . Job AddressEX_M_dA(_ Subdivision Name.`-- Owner's Name on Address Phone Contractor's Name License Phone TYPE OF WELL/PUMP WORK. NEW WELL WELL REPLACEMENTrn ❑ DESTRUCTION r PUMP INSTALLATI�11 ❑ SYSTEM REPAIR OTHER Ej .DISTANCE TO NEAREST: SEPTIC TANK: SEWER LINES DISPOSAL FLO. ;i (4lu� t PROP.'LINE FOUNDATION 21 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL L PROBLEM AREA 4.. CONSTRUCTION , I SPECIFICATION§ Industrial UOpen Bottom El Mane Dia. of Well Excavation IV DOmestic/Private /[5pG Gravel Pack E] Tr Dia. of Well Casing , Public nbther Lj lye 1.ta L Type of Casing Irrigation Eastern f i Approx. Eastern j ❑Cathodic-Protection Depth Specifications Geophysical Depth of Grout Seal L Other Type of Grout C-6 Sur1face; Seal Ins�talfed by Repair Work;'Done ❑ Type ofPum' H: State Work Done, Well Destruftio6 Cj- I Well 1)j' ameter r SeOing Material (tdp 50LI) Depth I FiherjMat,Aal' (Befow 5D') TYPE OF SEPTIC kORK' NEW INSTALeATIOp' I " (Nd septic tank or s6epage pit public sewer; is REPAIVADDiTION1 A Vj ivailAble'wit6in 200 f6et. permitted if Installation wi I i :serve: Residencel CDmmeftiai"i Oth6r 1 Number of-liOng 'nits: Number,of bedrooms Lot size I u haracter of oil: C 's to a depth of 3 feet: j, 1. i f Water table depth SEPTIC TANK ;Fj , Ty�ejmfg I I Cipacity f No. Compartmbnts 1 PKG. TREANE'NT ALT. Typ, p i e/Mf Oacity Method of C! Distanc�e tornear Disposa'l e s t:[—W Foundation - + 'Pro�perty Line -7 LEACHING LINE 1- 1D No;I & Len -of 0 1 nes Total , l6ngth/sjje%Ai *FILTERrBED DiStancetwnearest:� Wet]..jd t i Property ,Line "`SEEPAGE PITS ❑ De�th I I t Sife Number I SUMPS Dist LJ ancle tolnearect- j 1 Well Foundation : t�;DISPOSAL PONDS 1 1.. Property Line I hereby certify that I ave;pre ordinances,'state laws, and rul p!ared thi application-,_and-That�the work3will' be done accordancej with SanlJoa4uln county j . i i es-andiregdlati6ns of the.Sah-Joaquin1Locdl HelthjDist�rict,' Hofoc!_owrfer or licerised adentl�s signature certifies thefoll6win4: 1111cekify ih permit is issued, lishall not at'in the perfoy�mance of the work1for whic this employ Any �,ersoh in!such'man6`ier as to�jbecome subjeet to' workman� compensation i.1 awi of California-." Cohtractorl� hiringior'sub-co.ntractinq g'natute c6ftifles the f6llowing:'' "I Certify that in the peffortance,of the work for which! 1 this permit', is issued, I'sha emp y, rs,bns iubj4ct to workman'ls c6mpensation Taws of Ca 1 i fo r�ni a. Th e appli I fo 11 ed ihispec't' 1.. The a ions. Complete drawing awing on reverse side. Signed Title: 7 Date: I 1�9 0 IDF 1 EPARMENT.USE:ON L�� - j - 4al I Application Accepted by rea L '-' 06 Stk 466-6' ',� . Additional Comments: 1 i ii Pit or Grout Lodi 369-3621 - Jnspection by, Date ❑ Mantdca 823-7104 Final Inspection by I Date Tracy, 835-6385 Applicant -.Return all copies to:! En vi ronmen ta:I Heal Permit/Services 1601 Haz lton AvS., _0—Box 2009; Stk., 96201 FEE BASE AMOUNT DUE AMOUNT REMITTE6RECtIVED-BY j' DATE - INFO PERMIT NO. C>,U! EH 13-24 jREV.i 10/82 14-,26 i i. 10/B2 SOO