83-280 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMiT j p . ,� CP � SAN JOAQUiN LOCAL HEALTH UI51R 1601, E. HAZELTON AVE., STOCKTON� Telephone (209) 466-6791P APR '211%3 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) h � LOCAL HEALTH DISTRICT Application is hereby,made`to the Sari 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_ 9171 Wad.'A Subdivision Name Owner's Name Address 7CE 7df Phone _ S jtj Contractor's Name �� License No. . /Ga .37.-3 Phone i TYPE OF WELL/PUMP WORK: NEW WELL [VSYSTEM WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑!ust�rial ❑ Open Bottom_ Manteca Dia. of Well Excavation _r U✓ Do tic/Private ❑ GrawePack -" f Tracy y Dia."of`W ell`Casing ❑ Public [—, Other Delta Type of Casing Irrigation Approx. Eastern Specifications ti Cathodic Protection Depth l ❑ Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repajr Work Done ❑ Type of Pump e?j_ H.P. State Work Done - Well Destruction ❑ Well Diameter Sealing Material (top 5O') _ Depth I Filler Material (Below 50'.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (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 bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM t- Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number � i —SUMPS-.- - ��,D.isiance to nearest:_. well Foundation _ Property Line DISPOSAL PONDS ❑� Y �� f 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 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 performance of the work for which this permit is issued, 1 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 n , Title: Date: - 9• FOR DEP RTMENT,USE ONLY 466-6781 Stk Application Accepted by Area _ �C]- , Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 IDate �E ,,lton L Tracy 835-6385 Final Inspection by 1 Applicant - Return all copies to: Environmental Health Permit/Services 16 Ave., p.0. Box 2009, Stk., CA 95201 rEE BASE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT N0. NFD L a� �93-aqa 1 10/82 500 EH 13-24 REV. 10/82 14-26