84-448 - Laserfiche WebLink

Home Browse Search

�e c G�` k APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT gt�._L�l�g19 1601 E. "HAZELTON AVE., STOCKTON, CA PERMIT NO. tLj-a-I q9 W ' Telephone (209) 4664761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED GATE ISSUED L+,-2-0 S (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 Regul"ations of+the San Joaquin Lora1,H�a th District. ,{� / �/_ f , Job Address/) � �2J� AJlCA' &D 5 ZX�4400_f� ubdivision Name C /�6` !o'/Gc>�i'1 /Up.�4-� Owner's Name �P�G� SI"L1=SQN Address __ZZ,jj-:y_4//L j!C Rio Phone' �+ yy�� Contractor's Name �Q�fL S�C�/�—VLic 3.2 No. Phone TYPE OF WELL/PUMP WORK: NEW WELL o° WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION1P, SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK 2440 SEWER LINES F DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL .. 1 _ PITS/SUMPS �/f- INTENDED tINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private [RGravel Pack Tracy Dia. of Well Casing U/2 ❑ Public ❑Other ❑Delta Type of Casing F l Irrigation Approx. '❑ Eastern Specifications �,� ❑Cathodic Protection Depth f -- ..t Depth of Grout Seal �"� 't Geophysical *� . r : d/ti =Type of Grout Other Surface Seal Installed by PAN F z:9 4 Repair Work Done ❑ Type of Pump g N.P. z State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'). Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (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; "- Number of bedrooms t` Lot size f 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK_.Fj.,.,,,_Ty"pe/_Mfg.. 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 Size Number SUMPS I 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'Lgcal�Heal-th,District. C Home owner or licensed agent's signature certifies the,foliowing: "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." Contractor's hiring or sub_contracting'signature certifies the,following: "I certify tha't'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"mu t ll for all required inspections: Complete drawing-an reverse side. Signed XRT _ Title: ' Date: I ` FO PART NT USE.ONLY Application Accepted by / Area Z y1 .Stk 66-678 t Additional Comments: EL Lodi 369-3621 , Pit or Grout Inspection a� _Date 5 Manteca 823-7104 Final Inspection byDate Tracy 835-6385 7 I Applicant - Return all copi s t Environmental ea th Permit/Services 16 E. Hazelton Aver, P.O. Box 2009, Stk„ CA 95201 .. .w, .FEE'" _BASE.._ --AMOUNT-DUE,. . _"AMOUNT.REMITTED RECEI.YED..BY.--... ..• _.,.,.DATE..: -..—PERMIT,NO...s..L"'a� � INFO EH 13-24 REV. 10/82 10/82 500