86-1035 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 yp DATE ISSUED g / T EXPIRES 1 YEAR FROM DATE ISSUED We4� f 0 �17APERMIX- (Cq in Triplicate) /'t x �/�i,"�c� "tiff• c x - _ 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 Regulations of the San Joaquin-Local Health District. Job Address 23 - 7 3 6. ` Subdivision Name Owner's Name @ru 2► O e s Address Phone I contractor's Name » C Aa6 License No. 2<43919 Phone 92�� G.3 - J ' TYPE OF WELL/PUMP WORK: NEW�WELL [] WELL REPLACEMENT E] DESTRUCTION ❑ �. PUMPS INSTALLATION F-1SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEAREST: SEPTIC'TANK ;I SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION A AGRICULTURE WELL OTHER WELL PITS/SUMPS �] INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k E) industrial F-JSOpen'Bottom ❑Manteca Dia. of Well Excavation � L.l Domestic/Private .- ❑Gravel Pack F-1 Tracy of Well Casing 4 {V� 113 Public F-1 Other E]Delta Type of Casing ` ❑ Irrigation Approx. ❑Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout t j Other Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done E Well Destruction CJ Well Diameter. Sealing Material (top 50') - Depth � Filler Material (Below 50') f ,—,TYPE_,OF-SEPTIC.WORK:,,,NEW_INSTALLATION. IO,REPAIR/ADDITION (No septit tank or pit permitted if public sewer IS- .—,TYPE- s„� - 0 ' � �- - within 200 feet:)�""-"'"'�' Installation will serve: Residence _ Commerci'al,';= Other 4 � Number of living units; I . Number of bedroorifts 3� Lot size, Character of-soil to a depth of 3 feet: 7Water table depth °.Ca No. compartments C SEPTIC TANK Type/Mfg P,?��.�sT� parity �,ZOo ( PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of'Disposal. i. SEWAGE SYSTEM`- Distance to nearest: Well Foundation 3 Property'Line F DESTRUCTION. - Total length/size LEACHING LINES No. & Length of lines : is 5s FILTER BED E] Distance to nearest: Wel-I.- Foundation Property Line SEEPAGE PITS ❑ Depth J Size y Number SUMPS Distance to nearest: Well /0 U Foundation, �� ;Property Line DISPOSAL PONDS ❑ W� y" " ""k,! 1 I hereby certify that I have prepared this application and Oat the work will be done in accordance with San Joaquin county ,. �. ordinances, state'la`ws;"and"Pules`and regulatitins'of the San-Joaquin Lacal Health District:- Home owner or licensed agent's si nature cert ifies'the following: "I certifythat in 'the performance of the work'for which this permit`is issued, I shalnot employ any person in such manner s 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 rsons subject'to workman's compensation laws-of+Galifornia. ?. i1 7, The applicant I1 for 11 requi ed inspections. Complete drawing'on reverse side. _ - - p! Signed X ffl'Y Title: 2 Date: - FOR DEP TMENT tlSE ONLY Stk 466-6781 FOR D�Application Accepted by ❑ ., f Additional Comments: �` "^ ! '� s �! Lodi 369-3621 Manteca 823-7104 1 t Pit'or�Grout Inspection by Date a ^`Final I spection by Date L7 Tracy 835-6385 ^Applicant - Return all copies to: Environ Z Health Permit/services 1601 E. Hazelton Ave P:,O: 'Box 2009; Stk., CA4 95201 L„ t FEE BASE AMOUNT 'DUE AMOUNT REMITTED RECEIVED BY DATE d . ' PERMITN'0. �' INFO 1 635 x 10/82 500 -...e.�.�.-�.�r EH 13-24 REV. 10/82 14-26