84-680 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HA2FLTON AVE., STOCKTON,ICA PERMIT NO. Telephone (209) 466-6781.! ,, PERMIT EXPIRES 1 YERR FROM DATE I55UE0 DATE ISSUED i (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin .Local Health District, Job Address ,J Subdivision Name , � , �/ %`/7Q-�j yf Owner's Name Rd ress 3 Q ( "Z Phone T Contractor's Name OLicense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL r] WELL REPLACEMENT DESTRUCTION LJ PUMP INSTALLATION- L SYSTEM REPAIR OTHER DISTANCE'TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL J OTHER WELL r' PITS/SUMPS S INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom Manteca 3, Dia. of Well Excavation Domestic/Private 'I 0 Gravel Pack Tracy Dia. of Well Casing ! Public 6: f� [j Other Delta Type of Casing Lj Irrigation f ��,, Approx. Eastern - E F-1Cathodic Protection Depth Specifications , f Geophysical I1 } Depth of Grout Seal U Other Type of Grout p l Surface Seal Installed by N Repair Work. Done Type of Pump H.P. State Work Done Well Destruction LJ Well Diameter Sealing Material (top 50') Depth, Filler Material ($elow 50') TYPE-�.OF SEPTIC WORK: NEW INSTALLATION LJ ,REPAIR/ADDITION J (No septic tank or seepage pit permitted'if public sewer is 1 available within-200 feet.) Installation will serve: Residence A-,' Commercial Other Number of living units: / Number of bedrooms Lot size f/2,�9 ,� 137. Character of soil to a depth of 3 feet: Water-table-dept-h-... SEPTIC TANK E!r Type/Mfg apacity d&Y- No. Compartments PKG. TREATMENT PLT. L Type/Mfg Capacity "—� ,Method of Disposal SEWAGE SYSTEM Distance to nearest: Well / Foundation DESTRUCTION Property. Line S LEACHING LINE No. & Length of lines 3 - Z1O Total length/size _ FILTER BED Distance to nearest: Well Foundation-7� Property-Line y l SEEPAGE PITS Depth _ Size /?l ' Number 3 SUMPS L1 Distance to nearest: Well 5'p Foundation /�Q( Property Line DISPOSAL PONDS 1..1114�AnYYI� 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 workmant-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 persons subject to workman's compensation laws of California." The applicant m st call for all required inspections. Complete drawing on reverse side. Signed X /, Title: }��G� Date: OV1EPARTME USE ONLY J Application Accepted'by Area f 5tk 466-6781 Additional Comments: ... ;Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date /yL10 Tracy 835-6385 , Applicant - Return all copies to: En / onmental Health Permit/Services 1601 E. Hazelof n Ave., P.O. Box 2009, Stk., CA 95201 I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO t Lis EH 13-24 REV. 10/82 10/82 500 14-26 {