83-743 - Laserfiche WebLink

Home Browse Search

v t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT $3 u"1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 s3==" ._-X� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED - (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. oQ Cb Job Address l2 73.3 Va-)i 1,,/ Lane— S�ubdivision Name Owner's Name Address /. O.r pV 3 j6 i Phone J_17?—2 `&3 1 Contractor's Name .� H �m. License No. f 6 2� PhonldO_ 823 `�/3 -_ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ /] DISTANCE TO NEAREST: SEPTIC TANK AS' SEWER LINES c_ DISPOSAL FLO./ Q PROP. LINE 40 FOUNDATION *Q Fy�. AGRICULTURE WELL laee f-'X_ OTHER WELL PITS/SUMPS fyJC?7C. - . . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Bottom U 0 en Manteca•-/zj�e�P � Dia. of Well Excavation Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Irrigation 126.1 Approx. ❑ Eastern Type of Casing PUC C1r�gS 140 ❑Cathodic Protection Depth Specifications clas$ % Q ❑ Geophysical Depth of Grout Seal- 3_0 k;t Lf Other Type of Grout ne-a ow—,e:-3L, Surface Seal Installed by Repair Work Done E] Type of Pump S u13 H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is v Installation will serve: Residence _ Commercial _ Other available within 200 feet.) 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line 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 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 st c 11 for a 1 required inspections. Complete drawing on reverse side. Signed X � w�� Title: ,f= Date: 0t0 EP RTMENT U ONLY Application Accepted by Area � ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by U Date _ 7j >gt Manteca 823-7104 Final Inspection by Date - + i�V ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental ealth Permit/ ices 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO FS3-"7 v� o EH 13-24 REV. 10/82 10/82 500 14-26 t1-V;