83-1112 - Laserfiche WebLink

Home Browse Search

i r F 4 ; APPLICATION FOR PERMIT — .SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. �3- } ��- Telephone (209) 466-6781 L ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 a d Regulations of the San Joaquin Lo 1 Health District, Job Address �F Subdivision Name Owner's Name k Address 4;11 Contractor's Nam License No. Phone TYPE OF WELL/PUMP WORK: NE4i WELL ❑ WELL REPLACEMENT. ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ x DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLO. PROP. LINE �] FOUNDATION l AGRICULTURE WELL OTHER WELL PITS/SUMPS M INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casings 17Public ❑ Other ❑ Delta F Type of Casing Irrigation Approx. ❑ Eastern Dth Specifications e ❑Cathodic Protection p Depth of Grout Seal 17 Geophysical U Other Type of Grout Surface Seal Installed by i Repair Work Done ❑ 'Type of Pump , H.P. State Work Done Well Destruction Lf Well Diameter! Sealing Material (top 50') Depth Filler Material (Below 50') i i111i 1�1��Ii IIIIYI 1� TYPE OF,SEPTIC WORK: -NEW-INSTALLATION- ""'REPAIR No septic tank or see ae p it—permifted 'ifublic s ' eweris available within U ADDITION/. �( P P�9 p a 200 feet.) Installation will serve: Residence _� Commerciale_ Other Number of living units. ~'Number of bedrooms " Lot size 71�L Character of soil to a depth of`3 feet: e Water table depth SEPTIC TANK ❑ Type/Mfg 6_4.1 3 rs LO R A Capacity 7 e„b No. Compartments 'Z PKG. TREATMENT PLT. ❑ Type/MfgI J?M C Capacity I Method of Disposal &1 SEWAGE SYSTEM Distance'to nearest: Well C a Foundation 10 Property Line ) DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/s.ize cj 0 FILTER BED ❑ Distance4to nearest: Well Foundation Property Line r .SEEPAGE PITS Y� CIY Depth o�S Size 33 Number SUMPS l_� Distanc enearest 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 following: "I certify that it 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 applic must call for all aired inspections. Complete drawing on reverse side. > Signed X Iitle: _l Date: , t!•` a" PAR ENT U NLY Application Accepted by / ' Areay` ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date )Q jJ-Q3 ❑ Manteca 823-7104 Final Inspection by Date Tracy 835-6385' Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 4 _ �//fr' � 10/82 500 14-26 `� I I '