83-1213 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR;PERMIT SAN JOAQUIN LOCAL 'HEALTH DISTRIC 1601 E. HAZELTON AVE. •STOCKTON CA p ' ' O CT f fGi 1 PERMIT N0. �� A)A Telephone (209).-.466-6781 f ! �jA� fQA DATE ISSUED _� - PERMIT EXPIRES 1 YEAR FROM DA_-F.E, ISSUED]` QUIN LOCAL (Com ete:rn "`HEALTH DISTRICT "S '+ p 1Cate)ai - -:t'--" Application is hereby made to the San Join Local Health D ct�<for a;p�• nit°to onstruct 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 um and the Rule nd Regulations of the San Jo n Local Health District<�' - - /p p j Job Address Subdivision Name eQL 1'✓1 ' Owner's Name 9 ddress 4 n f U �phoneContractor's Nameicense No. TYPE OF WELL/PUMP WORK: NEW WELLELL REPLACEMENT DESTRUCTION (i�' Ob wS PUMP INSTALLATIOEy r- -_�SSYSTEM REPAIR ❑ OTHER 0 W f ` DISTANCE TO NEAREST: SEPTIC TANK _ ._ SEWER LINES t- DTSP05AL FLD. 75 PROP. LINE 50-1-- �} FOUNDATION AGRICULTURE WELL "DTiiER WELL PITS/SUMPS r z -.- ---- .u. - - .. _. _Y . T INTENDED U5E TYPE OF WELL- PROBLEM AREA CONSTRUCTION Sf;_ECFFIL"ATIONS Industrial — pea Bottom Manteca Dia. of Well Excavation �r 5-4 2A r 91<-�stic/Private �-J Gravel Pack Q Tracy Dia. of Well Casing Public Other Delta irrigation Type of Casing LI 9 Approx. Eastern Specifications F-1Cathodic Protection Depth ` � .- Depth of Grout Seal&ophysica1 U Other Type of Grout Surface Seal Installed by Repair Work Done Ej Type of Pump &RH.P. State Work Done Well Destruction d Well Diameter ---4�- Sealing Material (top 501) Depth 2��° � Filler Material (Below 501) _ ^T TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U U (No septic tank or seepage pit permitted if public sewer is -� available within•200 feet.) �} Installation will serve; Residence _ Commercial, Other y r � Number of living units: Number of bedrooms � Lot size Character of soil to a depth of 3'feet: ( Water table depth " •` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. Type/Mfg Capacity Method of disposal +r SEWAGE SYSTEM �-f Distance to -n'earestn Well Foundation Property Line DESTRUCTION I--E .F G` , v LEACHING LINE U No. & Length of lines Total length/size FILTER BED 7-] Distance to nearest: tWell Foundation Property Line SEEPAGE PITS L Depth Size' � - -�Number SUMPS L , Distance-to:nearest: Well Foundation Property Line DISPOSAL PONDS I, hereby certify that I have prepared this'applicetion 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 fo Mowing:. "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mdnner�as to become subject to workmant compensation laws of California." Contractor's hiring or sub-contracting-Signa-tune certif-ies.the following: "I `certify that in the performance of the work for which this permit is issued. I shall empl y persons subject toyworkman'.s compensationilaws of California." The applicant ust call for all r uired inVectlon_s#'Complete dr ;ng on revdrse side, p Signed K Title: _ B P _ Date: R DEPA MENT USE ONLY P' t Ap ica ion Accepted by Area _C) _ Stk 466-6781 '` Y Additional.Comments: A 1.11 Lodi 369-3621 Pit or Grout Inspection by Date J Manteca 823-7104 ' Final Inspection by pbte �F.� Lj Tracy- 835-6385 n.,,.. Applicant - Return all copi s_Rto: En vironmen 1 Health Permit/Serv:ices;lbOLEE.;'Haz ton A6e., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTEO RECEIVED BY DATE PERMIT N0. 1 INFO I All EH 13-20. RFV. 10/82 _/ /G�` - d 1 �L 10182 500 ' 14-26 GDA � t& !-'