83-750 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVL_ STOCKTON,, CA PERMIT NO. 7 S O �` ► Telephone (204) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 rd�,nance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulati11 of the San Joaquin Local alth D, ct- Job Address Subd' n od- Address Phone Owner's Name � � Contractor's Name License No. Phone . J c3l TYPE OF WELL./PUMP WORK: NEW WELL P❑ 'WELL.REPLACEMENT 0 1f' DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR I]F OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF°WELL� ti PRQBL'EM AREA CONSTRUCTION SPECIFICATIONS tJ Industrial U Open Bottom Manteca.., Dia. of Well Excavation U Domestic/Private Gravel Pack E,Tr Dia. of Well Casing Public Other ,E]Delta Type of Casing V Irrigation I! 'v Approx..- []Eastern Specifications Cathodic Protection Depth � Depth of Grout Seal _ Geophysical I�iType of Grout Uj Other eor Surface Seal Installed by �f } ! , t" Repair Work Done �f�Type�of Pump H.P> State Work Done Well Destruction U Well Diameter Sealing Material (top 501 _ De t 4 +_k Filler Material (Below 50') �O^ � rv' pa TYPE•,OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is 7 available within 200 feet.) r Installation will serve: Residence Commercial Other ` Number of living units.: Number of bedrooms " Lot size a Water table depth �sCriaraeter of soil to a: depth of 3 feet: Capacity Compartments � No. Compartmen , SEPTIL,TANK Type/Mfg 5 Ca acity4 Method of Dis LoospI PKG. TREATMENV kT Type/Mfg p SEWAGE.SyTTEM x- 4' DiJ stance to nearest: Well Foundation — 0 Property Line 10 10"L ''DESTRUCTION Q �: LEACHING LINE No. & Length of lines Total length/size FILTER BED it Distance to nearest: Well / 1J Foundation Property Line SEEPAGE PITS i DepthSize Number r � � k SUMPS oistance to nearest: Well �,;�� Foundation 1._.JL--_— Property Line f LI DISPOSAL PONDS i } I hereby certify that 1,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 ne issued, T shall not employ any person Contractor's hiring or 'sub-contracting signature certifies the following:in such manner as to become subject to workman tion laws of California." 11 certify that in the performance Lof''t he work for which a this permit is issued, I shall employ persons subject to workman's compensation laws of California." �] The applicant ust 1. for all uired inspectio Complete dra ing or reverse side. Date: / tom' Signed X Title: Application Accepted by Area 0 D PA TMENT USE ONLY l�� Stk 466-678 ab— �y � Lodi Additional Comments:, Manteca 823-7104 f Pit or Grout In by Date L� + Final Inspection by Date J ❑ Tracy 835-6385 Applicant - Return all':copie to: Environmertal H lth Permit/Services 1601 E. azelton Ave., P.O. Box 2009, 5t k., CA 95201 !AIV AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. lcc -SC3 10/82 500 EH 13-24 REV. 10/82 ' 14-26