83-794 - Laserfiche WebLink

Home Browse Search

2 APPLICATION FOR PERMIT SAN ]OAQUiN LOCAL HEALTH DISTRICT (( 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. ,3 `} Telephone (209) 466-6781 I PERMIT EXPIRES I YEAR FROM DATE ISSUED 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 and Regulations of the San Joaquin Local Health District. Jab Address��"2 jQy�fy Subdivision Name C f Owner's Name p Address s Phone Contractor's NameAloutLicense No. —3 Phone O TYPE_PF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION F-1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open BottomManteca ❑ Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel PackTrac Public � y Dia. of Well Casing P L� Other ❑ Del to " �-a Irrigation Type of Casing g Approx. [] Eastern ❑ Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal 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 50') Depth Filler Material (Below 501) W TYPE OF SEPTIC WORK: NEW INSTALLATION !`��tT REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is r Installation will serve: Residence Commercial Z( Other available within 200 feet.) VA Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: /.ay Water table depth SEPTIC TANK ❑ Type/Mfg 4fZe7LOrd, P4,t9Z.V16< Capacity Tgvo 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 PITSDe th [� P 2,�' Size � Number IV f SUMPS ❑1 Distance to nearest: Well Foundation 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 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 workman5 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 all requi^ d inspections. Complete drawing on reverse side. Signed X 924 Title: Date: OR DEPARTMENT USE ONL.Y. 729 3 Application Accepted by ��, � � G ?,LC1�(r rea �Z �•S. 66-6781 Additional Comments: ✓4—� Gyvca[i ❑ Lodi 369- 21 Pit or Grout Inspect'yn by Date T' � ❑ Manteca 823-7104 Final Inspection by Date b ❑ Tracy 835-6385 Applicant - Return all cope o: 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 o o ICcA161T/VAJf.' Na l�..dGc� ai �i�...,✓ cw.�izc� c.>.w� EH 13-24 REV, 10/82 � � +J � 'wi0/82 500 14-26 ;0 �'�✓