83-1071 - Laserfiche WebLink

Home Browse Search

k APPLICATION FOR PERMIT - SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON RUE., STOCKTON, CA PERMIT NO. � C��{ ��i+�GLI` F'^s � "sC, P: !°ye`_� SERVICE Telephone (209) 466-6781 DATE ISSUED �3 63 SO. CrD Z S:0 f„:? 5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {rh.4F,3-. 2'1� Gcc+.isa"" sL'te,_•;�L67�1.�. - � (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 1 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 th'e.San Joaquin Local Health District. -r"s �f Subdivision Name Job Addressi�,1- � -� •a - s Address Owner's Name Q s� , ' Phone _ , Contractor's Name ..License No. r. Phone — [ TYPE OF WELL/PUMP WORK: NEWJWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATION I' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing ❑ Public ❑ OtherDelta ❑ Type of Casing V Irrigation iR pprox, Eastern Specifications } _ . �JCathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') r� TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) n Installation will serve: Residence A Commercial _ Other + `? �4S ll Number of living units: �_ Number of bedroo s Lot size p , Water table depth $ .< Character of soil to a depth o1 3 feet: �I SEPTIC TANK Type/Mfg Capacity n�No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Capacity SEWAGE SYSTEM Distance to nearest: Well G:/Y undation _-�v— Property Line �� - 4 .; DESTRUCTION I _ �) LEACHING LINE No. & L'ength of lines Total length/size "Afwoundation Property Line �' FILTER OLD ❑ Distance to nearest: Well) _GtOzb _� F Number SEEPAGE PITS Depth _^ Size e / �/�( SUMPS U Distance to nearest: Wel l/� oundation 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 i 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 workmant 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_ l Employ persons subject to workman's compensation laws of Caifornia." The applicant l all requir ins tions. Complete drawing on . vers side. - Signed X �. Title: Date: ENT U LY ❑ Replication Accepted Area5tk 466-6781 _0122- i Lodi 369-3621 Additional Comments: t�7 Manteca 823-7104 { Pit or Grout Inspection by Date -� �O�' ❑ E Date Tom'/= V t-1Tracy 835-6385 Final Inspection 'by Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 1 r FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO # 10/82 500 EH 13-24 REV. 10/82 4 14-25 „