83-597 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH-.DISTRICT *q q 7 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. p — i Telephone (209) 465-6181 / a337 2 DATE ISSUED [Q J PERMIT EXPIRES 1 YEAR FROM 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 and Regulations of the San Joaquin Local Health District. Job Address 9?11/z/ /yi /74c".•1/ lit/ Subdivision Name Owner's Name Address Phone Contractor's Name.S tin License No. Phone �%��-Q�Q7 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r .1 PUMP INSTALLATION (] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �{ ❑ Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑Other [] Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal � ❑Geophysical Type of Grout ❑Other Surface Seal Installed by AA Repair Work Done ❑ Type of Pump H.P. State Work Done CHCS Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') + TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION l� (No septic tank or seepage pit permitted if public sewer is y" available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: I Number of bedrooms 3 Lot size C IP 0 Character of soil to a depth of 3 feet: CL . Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.�Compartmentsl PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation e Property Line 1R DESTRUCTION LEACHING LINENo. & Length of lines 1 - Total,lyngth/s i ze ZOO Im FILTER BED ❑ Distance to nearest: Well ,�_ Foundation /Z Property tine Number` SEEPAGE PITS [�( Depth �.S Size � SUMPS Distance to nearest: Well Foundation �sj - Property Line y DISPOSAL PONDS ❑ 1 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 workmanIs 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 must1 r al requi d in ctions. Compe: drawin on�r v rse si Signed X c Title: �-/ 'rL�Date: Z 3 P ENT USE ONLY Area Stk 466-6781 Application Accepted by 1 ` Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ' ❑ Manteca 823-7104 Final Inspection by Date Tracy 835-6385 ❑ f P.O. Box 2009, St k., CR 9 Applicant - Return all c e o: Environmental Health Permit/Services 1601 E. Hazelton Ave., FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 4 (Q3 g3 3-5 l 10/82 500 EH 13-24 REV. 10/82 /� 14-26 V�