SU0012614 - Laserfiche WebLink

Home Browse Search

.t s.? s pg APPLICATION FOR PERM:T /' QQ / r� � I Sa.P: JOAQLi': LOCAL HEALTH DISTRICT �f 1601 E. HAZELTON AVE., STOCKTON, CA PFRMIT NO, a //77 )—q Telephone (209) 466-6781 DATE ISSUED !W 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f O L Q/ H�� (Complete in Triplica.e) 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 Oistrict. Job Address_ '� i l ,21, Subdivision Name Owner's Name Z Address Q, Phone 94,61?&99 Contractor's Name License No. �s� sol /3 Phone 1741,9 f 7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION QJ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLO. _ PROP. LINE FOUNDATION ( AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE Or WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pd Industrial OpenBottom 0 Manteca Dia, of Well Excavation U Domestic/Private Gravel Pack Tracy Dia. of Well Casing 17 Public Other Delta Type of Casing yP g (�( Irrigation Approx. ❑Eastern Cathodic Protection bepth Specifications @^�/ Depth o` Grout Seal _ U Geophysical !1 Type of Grout Other . Surface Seal Installed by Repair Work Done 1] Type of Pump ��_ H.P. State Work Done .tom►,►^ 1��+�,1t r„�. Well Destruction ❑ Well Diameter Sealing Material (top 50'). Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (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 hedrooms Lot size �. Character of soil to a depth of 3 feet: Water table depth SE?TIC TANK Type/Mfg Capacity No. CoinparfrfiCnt's'•- F PKG. TREATMENT PLT. LI Type/"Mfg Capacity _ Method of Disposal SEWAGE SYSTEK Distance to nearest: Well Foundation Property Line — DESTRUCTION LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED Distance to nearest: Well Fe undatior Property Line i SEEPAGE PITS ❑ Depth Size Number i SUMPS L 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 fDllowing: "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 perfomance of the work for which this permit is issued, : shall emoloy persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing ,00n,reverse side. c�^� Sicned X 1- Title: ��z Date: UOR DEPARTMENT USE ONLY / Ap�ication Accepted by Area 0 Stk 466-6781 x Additional Comments: �, Lodi 369-3621 7 ?it or Grout Inspection by; Date �] Manteca 823-7104 Final Inspection by A17 _ Date e ❑ Tracy 835-6385 - Applicant - Return all copies to:I Environmental Health permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95522DI FEE ' BASE AMOUNT DUE , AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. \' pV,',✓`�Jw /��- _ INFO EH 13-24 REV. 10/82 I 10/82 500 14-Z6