SU0004820_SSNL - Laserfiche WebLink

Home Browse Search

1.04 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED 3 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 and Regulations of the San Joaquin Local Health District. Job AddressL ;ew Subdivision Name LW Address !�V, Owner's Name Phare ' License No. 'Z Phone WL7 Contractor's Na L+ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT 0 DESTRUCTION PUMP INSTALLATION [] SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1J Industrial FJ Open Bottom Manteca Dia. of Well Excavation Domestic/Private �Gravel Pack ❑Tracy Dia. of Well Casing Public F-1 Other ❑ Delta Type of Casing Ls Irrigation Approx. [] Eastern Specifications Cathodic 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 O ti Well Destruction f_1Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') �+ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is V; available within 200 feet.) Installation will serve: Residence _ Commercial ^ Dther Number of living units: Number of b d ooms --49 --- Lot size Character of sail to a epth of 3 feet: Water table depth f' d Capacity No. Compartments SEPTIC TANK Type/Mfg PKG: TREATMENT PLT. Type/Mfg x Capacity Method of Disposal SEWAGE SYSTEM 0 Distance to nearest: Well '/�}� F4und�tion c � Property Line 01 DESTRUCTION ��— LEACHING LINE )_J No. 1, Length of lines � - yQ _ Total length/size � X 2 FILTER BED F-1Distanceto nearest: Well 7 Foundation Property Line - 0 Size Number _ SEEPAGE PITS Depth r� � SUMPS IJ Distance to nearest: Well � .,_ Foundation �J Property Line DISPOSAL PONDS CI i.. 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 L permit is issued, I shall not employ 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: "!-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 applican must cal fo all required inspections. Complete drawing onreverseside. Signed X Title: 1/ Date: FOR DEPARTMENT USE ONLY © Stk 466-6781 Appl' ion Accepted by Area - Lodi 369-3621 Additional Comments: V Pit or Grout Inspection Date L_] Manteca 823-7104 -. Date Tracy 836-6385 Final Inspection by Applicant - Return all copies o: Envir nmental Health Permit/Services 16 £."aelt.nAve., P.O. Box 2004, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED - RECEIVED BY DATE PERMIT NO. INFO y as 3 �3-� 10/82?_ ,5.00 EH 13-24 REV. 10/82 14-26