83-458 - Laserfiche WebLink

Home Browse Search

i i APPLICATION FOR PERMIT Ac�\� 51 iN LOCRL HEALTH DISTRICT AVE., � 16001 E.E. HAZELTON RVE„ STOCKTON, CR PERMIT N0. Ll1 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES i YEAR FROM DATE ISSUED. ' (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 for well/pump and the Rules and Regulation of the San Joaauiin, Local Health District. Job Addres (�'�sE',v' � Xe� "` Subdivision Name Owner's NameAddress d V Phone Contractor's 'V-61,11-A'147 CbLicense No. 720;a(y Phone s� Q_�fQ — TYPE OF WELL/PUMP WORK: NEW WELL WELL'REPLACEMENT '0 DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR C] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS {��n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom F Manteca Dia. of Well Excavation �} LJ Domestic/Private ❑ Gravel Pack -[].T racy Dia. of Well Casing Public �j Other ❑ Delta i Type of Casing Irri ation• A rox. Eastern L 1 9p ' ' Depth Specifications 1 Cathodic;Protection Depth of Grout Seal Geophysical +.,K TypeJ. of Grout Other . "� Surface,Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction.U Well Diameter Sealing Material (top 501) ' Depth Filler Material (Below 50') # , TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ .(No septic tank or seepage.pit permitted if public sewer is (fr 1 g available within 200 feet.) ` Installation will serve: Residence r Commercial Other -h Number of living units': �_ Number of bedrooms *Lot siXe _ `[i�CJ�Jt.I�� h Character of soiltufa epth of 3 feet: / Water table depth SEPTIC TANK [Type/Mfg ��I'72C, /+�iliyu-Q� Capacity Tom` No. Compartments PKG. TREATMENT PLT./'7 Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ;� Distance to nearest: Well Foundation �Q � Property Line DESTRUCTION LEACHING LINE U No. &Length of lines — G (j Total length/size FILTER BED / Distance to nearest: Well Foundation /fl - Property ne SEEPAGE PITS/ Depth {j Size Number! SUMPS f U Distance to nearest: 60 Property Line 6__ __� 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 wofor which t).s permit is issued, I shall employ persons subject to workman's compensation laws of. California." The applicant ust call r 1 required inspections. Complete drawing o r erse side. uf y' 4 Signed X � Title: i Date: OR DEPARTMENT USE ONLY A pl7ation Accepted by Area Stk 466-6781 Additional Comments: odi 36973621 Pit or Grout Inspection b Date Manteca 823-7104 Final Inspection by DaTracy 835-6385 Applicant - Return all copies o: Envir mental Health Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 rNFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO: ^� EH 13-24 REV. 10/82 10182 500 14-26, � F