83-1179 - Laserfiche WebLink

Home Browse Search

DAPPLICATION FOR PERMIT G C I 1 19 q 3 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �+ Telephone (209) 466-6781 SAN _IOAQUIN LOCAL DATE ISSUED HEALTH DISTRICT PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDsl * cam ,. a (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 He��llt�hh��District. I Job Address n.i. Gt+tz* {� —� �ff"Si7bdllesion Name Owner's Name A%S_* Address -_L_L2 7 E, Mary 4(_ _ Phone Contractor's Name puryiance ri ers r� License No. -4 3 7 1 qZ 3 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [_1 DESTRUCTION ❑ at..�, pt. ltaCPC PUMP INSTALLATION SYSTEM REPAIR OTHER WJ PW-110 /I}} Jr.S.K{/lJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. r Wr^P FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Oper Bottom Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack Tracy Dia. of Well Casing 1-1 Public LJ Other Del to D n Type of Casing jj Irrigation Approx. L] Eastern r LICathodic Protection Depth Specifications Depth of Grout Seal {� Geophysical i TI Type of Grout U Other Surface Seal Inst/a�ll�ed by Repair Work Done ) Type of Pump ��, H.P, l� State Work Done i�Ii,__as2Ae— Dw Well Destruction ❑ Well Diameter Sealing Material (top 50`) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION [_J (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 Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Lf Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Ei Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FLIER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L 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." 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 applicVj�must 1] r all required inspections. Complete drawing on reverse side. Signed X Iitle: Date: NT USE Y Application ccepted y Area _ Stk 456-6781 Additional Comments Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7144 Final Inspection by E" Date L7 Tracy 835-6385 Applicant - Return all copies to. E ironmental Hea h Permit/Services 1601 E, hazel terlAve., P.O. Box 2009, Stk., CA 95201 [FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �PFRMIT IAL 10 1 EH 13-24 REV. 10/82 10/82 500 14-26