83-1107 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PEnNiiT c SAN JOAQLI', LOCAL HERLTH DIS-i, L OCTc� Q py 1601 E. HAZELTON AVE., STOCKTON, CA 0 - 3 1983 PERMIT NO. J �I 1 Telephone (209) 466-6781 �� t1 GATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSSA[I JOAQUIN LOCA (Complete in Triplicate) HEALTH U]STRICT 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 RulesandRegulations of the San Joaquin Local Health District. Job Address /i $ Subdivision Name Owner's Name Addres C /'1 Phone Contractor's Name �� /�, � License No. Phone S, TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _J I . 1Igdastrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump cc H.P. / State Work Done —2--.-K w Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other 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 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line ` DESTRUCTION V LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS I❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑I 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. 73 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 workmanis 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 must call for all required inspections. Complete drawing on reverse side. �j Signed X R� YY7.(°�,..w- .0 Title: ✓ Date: c�° v— - FO RTMENT USE ONLY Application Accepted by Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date 3 LI Tracy 835-6385 Applicant - Return all copies tk Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rINF01 EEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. �-- i0� j EH 13-24 REV. 10/82 10/82 500 14-26