83-529 - Laserfiche WebLink

Home Browse Search

f f Al APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 LC DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) .r 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. Jab Address 12_(pg �.45CJfWL. 12r.s'JW Subdivision Name Owner's Name 1GEI90.0I1M[o �}+�,�{��Q-� _ Address 5 �� Phone 4&9Z Sogl Contractor's Name QJAR=,&J.I y+ N License No. �k3�`� Phone L j(pp9 j"7 fA 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. LINC FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ff Open Bottom F1 Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack E] Tracy - Dia. of Well Casing 17 Public F-1 Other E] Delta T :Irrigation Approx. Eastern Type of Casing V Cathodic Protection Depth Specifications Depth of Grout Seal i7'Geophysical ; Type of Grout U Other Surface Seal Installed by Repair Work Done G Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION E:l REPAIR/,ADDITION 7A (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) O� Installation will serve: Residence X Commercial _ Other Number of living units: I ._ Number of bedrooms Lot size Character of sail to a depth of 3 feet: / lmpze Water table depth SEPTIC TANK [Ij Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM II�-� Distance to nearest: Well Foundation Property Line DESTRUCTION �l LEACHING LINE No. & teng'th of lines .--_ Ic � Total length/size x 01 FILTER BED Distance to nearest: Well Foundation ?.p Property Line �Q SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation �_ Property Line f40 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 it 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 hir' g or sub-contracting signature ce tifies the following: "I certify that i.n the performance of the work for which this permit is sued, I shall employ per s su t to workman's compensation laws of California." The applica 1 for 11 requi 5 t" ns Complen reverse side. f � Signed X itle: Date f TMEN E ONLY Application Accepted b Area Q _ Stk 466-6781 Additional Comments: [] Lodi 369-3 1 Pit or Grout Inspection by Datel/ Manteca 823-7104 Final Inspection by Date f� ?'—0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 0-10 k E.H 13-24 REV. 10/82 pm ao a l ffW"&6&Z r r`tm AMP-W oy ;ro Heew W,0/ 50C 14-2 6