84-298 - Laserfiche WebLink

Home Browse Search

G ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 Joaquin Local Health District. Job Address subdivision Name Owner's Name Address Phone 3.1-3 Contractor's Nameicense No. Phone ow. 1A&TYPE OF WELL/PUMP WORK: NEW WELL V7 WELL REPLACEMENT DESTRUCTION, — TPUMP INSTALLATION [ SYSTEM REPAIRT OTHER DISTANCE TO NEAREST: SEPTIC TANK —Zoo SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public F-1 Other Delta ❑ IrrigationSD 0? A pprox. � Eastern Type of Casing �yG GLA 3� JAS[]Cathodic Protection Depth Specifications Geophysical Depth of Grout seal as�V- ❑Other Type of Groat _ __ JZg7-D/(!/TAE w tek."s7w6) Surface Seal Installed by CAL w14Z.e[7R141,,y Repair Work Done E] Type of Pump H.P. State Work Done Well Destr`pction (] Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is 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.i ❑ Distance to nearest: Well Foundation Property Line SEEPAGEPITS$ E] Depth Size Number (SUMPS Z '' F-1Distanceto 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[hJring 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 1 for al required inspections. Complete drawin on a erse side. Signed X Title: Date: yy +� Application Accepted by FOR DEP TMENU ONL .5 20/aArea �5tk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date �$l E-1 Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Envir cental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA95 O1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY .DATE PERMIT NO. INFO -rI 13-o - EH 113-24 4-26 REV. 10/82 ��Z�o �r"� k l" �w.�,�� 10/82 5O0