83-783 - Laserfiche WebLink

Home Browse Search

f w APPLICATION FOR PER•iIT SAN ,lOAK IN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STGCKTON,i CA Telephone (209) 466-6781 PERMIT NO. PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED DATE ISSUEO �.._ 3 (Complete in Triplica�Le) Application is hereby made'to the San Joaquin Local Health District for a'pemit to construct acid/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 Re ulation of the San Joaquin Local Health District. Jab Address +[L-DR. Subdivision_Name 1 Owner's NameR C 1. %AS (1�.� Address Contractor's Name CLL �� Phone Ricense No. Q Phone Ud TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION " ,., ., PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEARESTISEPTI G..TANK>.•=1 w SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION ~� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ; -- -� ��— TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial ; _ U'Open Bbtto� Manteca Dia. of Well Excavation I Domestic/Private 'Q Gra".v"e1:Pa-ck Trac Public ma=r+ �-� y Dia, of Well Casing [-j Other � Delta V Irrigation Type of Casing Approx. Eastern F-ICathodic Protection 'Depth Specifications ❑Geophysical # Depth of Grout Seal ~ ❑Othert Type of Grout ) ['u�j Surface seal Installed by Repair Work Done Type of Pump 01 4� H.P. State Work Done �. Well Destruction ❑ Well Diameter Sealing Material (top 50') a P E _ _ Depth < Filler Material (Below 501) r t TYPE OF SEPTIC WORK: NEW INSTALLATION L:1 REPAIR/,40DITION ��d U (No septic tank or seepage pit permitted if public sewer is Installation will serve: ResidenceCommercial Other available within 20O feet.) Number of living units: Number of bedrooms — Lot size ! I! Character of soil to a depth of3 feet: Water table depth € w SEPTIC TANK LJ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal ; SEWAGE SYSTEM y-� Distance to nearest;.,Well* _j ,Four:dation ; • =-property Line ; DESTRUCTION f:EACHiNG-LhNE---�-��.-.No.�&-Length•of-lines--.- .-,��:.-a..,..,_,,..�„�,�,Total-Tength/size._,_,-,�,�.�.�...._;.. ,��' FILTER BED ' +- .-e - Distance.to nearest: Well .e wf Foundations a Property Line SEEPAGE PITS Ej Depths t Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �� r 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 workfor which this permit is i ued, I shall not employ any person in such manner as to became subject to workmant compensation law 3jof California." Contractor' iring or s b-contract' g signit certifies the following: "I certify that in the performance of the work for which - this permit - issued, sh 11 e 1 pers s subject to workman's compensation laws of California." k The applic ust call f 11d i q r pectiens. Complete dr i on re -side. Signed x T>r�QP Title: Date: Z L Application Accepted by OR D�PARTM g 3 eaStk 466-6781 Additional Comment Lodi 369-3621 Pit or Grout Ins ion by Date Manteca 823-7104 Final Inspection by r Date Tracy 835-635 j Applicant - Return all copies to: Environmental Health Permit/Services 16 1 E. Hazelton Ave., P.O. Box 2009, Stk?, CA 95201 3 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO EH 13-24 REV. 10/82 # 14-26 10y82 500 a i