84-422 (2) - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STQCKTON, CA PERMIT NO. X , Telephone (209) 466-6781 , ., PERMIT EXPIRES 1-YEAR FROM DATE ISSUED DATE ISSUED Z '� (Complete in Triplicate) I 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 L, and the Rules and Regulations of the San Joaquin Local Health District. 1C-JCIS Job Address t � e o2a�t �. .�//A/E ST' Subdivision Name ,40 7--d?- 0050,1 p Owner's Name _WyiD AIA 7�e"AAl Address 13Zg 1—)V, f&1Q2hone Contractor's Name FL_ays� E . [��p License No,.417, �� Phone }dS-397/ 4 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ,—PUMP-INS-TAL-L-AT-1-ON—F--SYli-T-EM--REPAIRr~„—U OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE " ATYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1J Industrial U Open Bottom F-1 Manteca Dia, of Well Excavation U Domestic/Private L] Gravel Pack Tracy ` 4 Dia: of Well Casing Public ifir{ Other } ❑ Del to 1) { Type of Casing LIIrrigation Approx''"'"[:]'Ea`stern'""'"`"'"`"""'"'"-``" ' ➢epth Specifications Cathodic Protection i•�� Depth of Grout Seal 1-1 Geophysical r Lj Other I Type of ,Grout h ; Surface Seal Installed by Repair Work Done Type of Pump yH.P.. State Work Done III Well'Destr-ction U Well Diameter Sealing Material (top 50') _ a, Depth Filler Material (Below 50') TYPE OF SEPTIC WORK': NEW INSTALLATION U REPAIR/ADDITION [(Na septic tank or seepage pit permitted if public sewer is available within 200 feet.) f Installation will serve: Residence ✓ Commercial _ Other Number of 1livinglunits: f-- Number of bedrooms ;I- Lot size 7�'WJ S s e eble depth t Character of soij..;.to_a-depth_of,3 feet: CGS Sr Wat r _a SEPTIC TANK Type/Mfg Capacity No. Compartments v 1 PKG. TREATME{VT PLT. Type/Mfg Capacity " Method of Disposal SEWAGE SYSTEM �--� Distance to nearest: Well Foundation Property Line DESTRUCT11ON H1.0 n LEACHING LINE Lri''l No. & Length of lines /—"gyp Total length/size 'X7�-/ �I FILTER BED Distance to nearest: Wel_) Foundation /p/ Property, Line SEEPAGE PITS .Depth Size ,�3 " Number J SUMPS e D Distance to nearest: Well AVA- Foundation 47' 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 rul:es�and regulations of the San Joaquin Local Health District. Home owner pr licensed agent's,ssignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall notemplpy 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 must call'for a11 , .required spections. Complete drawing on reverse side. / Signed X ' a Title: Date: ^y PARTMENT USE.ONLY Application Accepted by Area _ ' ' Stk 466-67$1 Additional Comments: s Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final; Inspection by DateYy�� Tracy 835-6385 z Applicant —;Return all copies to: Environmental alth Permit/Services 1601 E. Hazelton Are.., P.O. Box 2009, Stk., CA 95201 i • FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVEDBYDATE PERMIT NO, INFO CJD L4-1 V`i� EH 13-24 RREV: 10/82 '" � 10/82 500 14-26