84-217 - Laserfiche WebLink

Home Browse Search

APPLIEATION FOR PERIMI T + SAN JOAQ1j1N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, GA PERMIT NO. Telephone (209) 466-6781 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 Joa uin Local Health District. 1 Job Address [� Subdivision Name one Owner.s'Name Address Contractor's Name �,/�icense No. Zy Phone s TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR I— OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS, . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca - --Dia. -of Well -Excavation- Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public L OtherDelta Type of Casing- - Irrigation Approx. Eastern a Specifications Depth Cathodic Protection z Depth of Grout Seal Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done T Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION J (N° septic tank or seepage pit permitted if public sewer is: / available within 200 feet.) O Installation will serve: Residence 05 Commercial _ Other k Number of living units: Number of bedrooms -__ Lot size A,&n X Character of soil to a depth of 3 fe�eeeto: It Water table depth I ' Capacity �!1 e G, City /2oa- No-.-Gompartmemts - ,Z- SEPTIC TANK TYp /Mf 9 er, PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well pj�F°undation ----' � Property Line Z 6 r DESTRUCTION p— LEACHING LINE T� No. & Length of lines 3 Ke'" Total length/size 2��' r FILTER BED Distance to nearest: Well J Dd Foundation l� Property Line . SEEPAGE PITS ❑ Depth Size Number SUMPS L Distance to nearest: Well Foundation Property Line DISPOSAL PONDS h 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, 1 shall employ persons subject to workman's compensation laws of California." The appli nt must f all required inspections. Complete drawin pon reverse side. III Title: / Date: k Signed X FO PARTMEN USE ONLY �7 Stk 466-6781 Ap ication Accepted by Area �L� Lodi 369-3621 Additional Comments: Pit or Grout Inspection by Date LJ Manteca 823--71D4 Date L Tracy 835-6385 Final Inspection by //// CA 95201 Applicant - Return all copies to: EnvitLdnmental Health Permit/Services 1601/E. Ha elton Avg P.O. Box 2009, Stk., FEL BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DA;jTE PERMIT N0. ]NFO pp L 10/32 500 Eh 13-24 REV. 10/82 14-26