83-910 - Laserfiche WebLink

Home Browse Search

APPLICATION FDR PER,",;T SAN JOAQLi': LOCAL H=ALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT 40, 3 ! Telephone (209) 456-6781 DATE ISSUED PERMIT EXPIRES 1 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 Regulations of the San Joaquin Local Health District. Job Address r- 1VFJ/77M IC.I/, Subdivision Name Owner's Name . sdazA Address Phone _.Y9 & Contractor's Name ('�4/litlA-i�L� 0eJ44/,JL3ticense Phone 6� Q,?' TYPE OF WELL/PUMP WORK: NEW WELL r WELL REPLACEMENT X DESTRUCTION ❑ (�� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cj "- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ` PROP. LINE FOUNDATION GRICULTURE WELL OTHER WELL SUMPS INTENDED USE TYPE OF WELL PROBLEM REA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom anteca Dia. of Well Excavation FT110,mestic/Private e avel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta �j Irrigatiors E]Approx. Eastern Type of Casing _ P� W Depth Specifications /l(� /orf ❑Cathodic Protection Depth of Grout Seal 17 Geophysical Other Type of Grout Surface Seal Installed by LASpy i Repair Work Done ❑ Type of Pump H.-- H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') V t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 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 ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 persons subject to workman's compensation laws of California." The applicant mu c 1 for a 1 required ins ections. Complete drawing on reverse side. Signed X Title: Date: EPARTMENT USE ONLY Application Accepted by Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date - } 823-7104Final Inspection by Date (racy 835-6385 Applicant - Return all copies to: . Enviro mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE Lis PERMCIIT NO. I NFO4r f9 _1 - "6 l 1 EH 13-24 REV. 10/82 d J �� v,�} �yp yi 10/82 500 14-26 /�Y