83-1095 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL:HEA TH DISTRICT 1601 E. HAZ11T11 AVE., STOCKTON, CA PERMIT NO. 5�3-5_ C�.g C t� Telephone (209) 466-5781 �. DATE ISSUED•�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (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 andRegulation of the San Joaquin Local Health District. k Job Address f� 2 G+�c Subdivision Name ! Owner's Name Address Phone .Sas Contractor's Name I License.No. b� Z3 Phone _ V6b_�'6�r TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICRTIONS FI Industrial ❑Open Bottom ❑ Manteca x M1 Dia. of Well Excalation Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing Public Other Delta ❑ ❑ ❑ Type of Casing Lj Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection 1 Depth Depth of Grout Seal 01) Geophysical Type of Grout Q ❑Other 4 Surface Seal Installed by Repair Work Done [ Type of Pump (� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top — Depth Filler Material (Below 50') C TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is rn available within 200 feet.) M ` Installation will serve: Residence i Commercial _ Other Z [ Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK E] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Ei Distance to nearest: Well Foundation Property Line .r 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 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ] 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 workmans 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 must call for all required inspections. Complete drawing on reverse side. Signed X 6 W1 Title: Date: DEPARTMENT USE ONLY F� Stk 456-6781 Application Accepted by `ram Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Dates. � �� IL7� Manteca 823-7104 Final Inspection by a. Dat �s Z_ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 r1l BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. • G� a g3-1 Ggs 10/82 500 EH 13-24 REV. 10/82 14-26 _ i