84-376 - Laserfiche WebLink

Home Browse Search

o APPLICATION FOR PERMIT fSAN JOAQUiN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED DATE ISSUED (Complete it 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 jf4v7j GT A4;,,9oy/yiyy*F /e7rw4k bdivision Name Owner's Name Address Jb y00 Sa. /� cv .�3. Phone, Contractor's Name a /9 / scy License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 I J Industrial U Open Bottom [] Manteca Dia: of Well Excavation U Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing Public F-1 Other Delta ! Li irrigation Type of Casing 9 Approx. Eastern Cathodic Protection Depth Specifications " Depth of Grout Seal Geophysical Other Type of Grout Surface,Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION REPRIR/ADDITION fJ (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 .3 Lot size / e Character of soil to a depth of 3 feet: C A o Water table depth p SEPTIC TANK Ej Type/Mfg 54 CA ,- C'owe. Capacity 1400 No. Compartments :7. PKG. TREATMENT PLT. [J_ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEDistance to nearest: Well Foundation Property Line DESTRUCTION i-1 LEACHING LINE - U No. & Length of lines 3 9 D' Total length/size ;a P FILTER BED Distance to nearest: Well Joe Foundation 10 4F Property Line X5" SEEPAGE PITS rl Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ r] I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county fI 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 f 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 t call for all required inspections. Complete drawing on reverse side. ' I Signed X Title: Date: .Z FOEPARTMENT USE ONLY Application Accepted by _ rn Area _ Stk 466-6781 - Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: EnvironhferKal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 7 Iso EH 13--24 REV. 10/82 10/82 500 14-26