83-660 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 GATE 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 an`d/ Regulatio s of the San J n in Local Health District, Al Job Address `i a Subdivision Name A Owner's NameAddress Phone Contractor's ' License No. �� (� - Phone 3�g TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION ❑ , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 14 ELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation c Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Otler ❑ Delta Type of Casing Irrigation Approx, ❑ Eastern Depth Specifications F-1CathodicProtection Depth of Grout Seal ❑Geophysical Type of Grout U 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') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (XK'(`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: I Number of bedrooms Lot size l} Character of soil to a depth of 3 feet: Water table depth o SEPTIC TANK. ❑ Type/Mfg UIL 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 ❑ Distance to nearest: Well Foundation . Property Line SEEPAGE PITS ❑ Depth T/a Size _ ��Y27 Number. SUMPS Distance to nearest: Well /0 Foundation .10rO f Property Line f� DISPOSAL PONDS ❑ ..rte 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." Contractors hiring or sub`-contracting signature cert-ifies 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." I The applicant must call or 11 required inspections. Complete drawing pn everse side. Title: ��/ {late: Signed X --- -- R RTMENT USE ONLY Appli ation Accepted by Area -�_ ❑ Sttk�k 46fi-6781 Additional Comments: FA, di 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6365 Applicant - Return all copies t EnvironmV, &�hntal HPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 =� BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE I PERMIT NO. Z., (b) � EH 13-24 REV. 10/82 10/82 500 14-26