SU0003649 - Laserfiche WebLink

Home Browse Search

` D �, APPLICATION FOR PERMIT 1 � 190 SPN JOAQLiN LOCAL HEALTH DISTRICT PERMIT N0. S3 r lO FEB ,�- 193 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 DATE ISSUED 1pCAI- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEHtThl DI51 RIC T (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 rthe San Joaquin Local Health District. Job Address �Q� l A'T!•�DPYQ Subdivision Name Ov 1 b L �� T ' '� _ Phone ? ^ pQ Owner's Name � 4 _�.,.�/R� �T� �.n Address �n�// � � Phone ()U,Contractor's Name 01 AR1.L'keil _1 z�cIA-11cense No. `3 . 1 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER [-J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS OL, Industrial ❑ Dia, of Well Excavation Q`Open Bottom ❑Manteca - � Domestic/Private E]Gravel Pack ❑Tracy Dia. of Well Casing ❑Public ❑Other ❑Delta Type of Casing Lj Irrigation Approx. ❑Eastern Specifications �I ' ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Oone�s Type of Pump 50122 H.P. State Work Done fj�" AB F2 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') if TYPE OF SEPTIC WORK: NEW INSTALLATION F-1 REPAIR/ADDITION ❑ (No septic tank or seepage Pi availableewithinu200c seweris feet Installation will serve: Residence _ Commercial _ Other Number of bedrooms Number of living units: Lot size Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK F-1 Type/Mfg Capacity Capacity Method of Disposal PKG. TREATMENT PLT. E] Type/Mfg Property Line SEWAGE SYSTEM Distance to nearest: Well Foundation DESTRUCTION C] Total length/size LEACHING LINE 71 No. 8 Length of lines Property Line FILTER BED ❑ Distance to nearest: Well Foundation Depth SEEPAGE PITS EJP Size Number Property Line SUMPS U Distance to nearest: Well Foundation 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. Hone 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, I shall employ persons subject to workman's compensation laws of California." The applicant mus Z II l,Te9rired inspections. Complete dylwiy re°erse„^eL A�/fh Date: Signed (` �7..J AA Title: a/O`X��j��) C/��1;�_ -� CF EPARTMENT USE ONLY Area 13 ❑ Stk 466-6781 Application Accepted by U ❑ Lodi 369-3621 Additional Comments: Date _}� Manteca 823-7104 Pit or Grout Inspection by ka i/l❑ Tracy 835-6385 Date _ final Inspection by n Ave., P.O. Box 2009, St CA 95201 Applicant - Return all copies . Environmental Health Permit/Services 1601 E. Hazelto ., FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE 3 FERMTNO. INFO ( (p 10/82 500 EH 13-24 REV. 10/82 14-26