83-350 - Laserfiche WebLink

Home Browse Search

APPLICATION FFOR_PERM!T SAN JOAQU_1N LOCAL HFALTh DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA --PERMIT NO. 35 1 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! f (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 ea l V"trict. ! " Job Address 2 `b _ division Nrame Owner's Name 3h, Address 13 y. Phone. .3 3 License No A- 13 Phone �C p_�[_3 � j Contractor's Name --®-w— �OZj; TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ W PUMP INSTALLATION SYSTEM REPAIR 17 OTHER L DISTANCE TO NEAREST: SEPTIC TANK _ sZ� SEWER LINES 7 DISPOSAL FLD. gJ PROP. LINE FOUNDATIDN 30' AGRICULTURE WELL OTHER WELL PITS/SUMPS /A O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U'Open Bottom ❑ Manteca Dia. of Well Excavation f a Gl Domestic/PrivateGravel Pack Tracy Dia. of Well Casing ❑ Public Mother C1 Delta Type of Casing j Lj Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth ❑ e Depth of Grout Seal ❑Geophysical F Type of Grout ��+`�^- -t ❑Other Surface Seal Installed by d yia'h Repair Work Done ❑ Type of Pump H.P. State Work Done . Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') �--TYPE.OF SEPTIC WORK: ,NEW INSTALLATION L REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is — --a ,,,.:. , - ,, :->�,�.x- - available within 200 feet.)- Installation will serve: Residence - -Commercial _ Other Number of living units: { -: Number of bedrooms Lot size 4 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 ❑ Distance to nearest;..,We1J _Founda-tion Property Line DESTRUCTION LEACHING LINE U' s No. A_Length of lines Total length/size' Property FILTER DEO ❑ Distance to nearest: Well Foundation Line SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line I- ; ! DISPOSAL PONDS ❑ e 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-l-icensed-agent-s:.s-ignature certifies-the-following-:-"I4certify that--in-the-performance of._the-work-fnr-V4hich this—�- permit is issued, I shall not employ any person in such manner as to become subject to workmans compensation laws of California." CC Contractor's hiring or sub-contracting signature certifies the following: "I certify that i6'.the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." i The applim st call fo 11 requijred inspections. Completd}rawing on reverse side, t Signed X itle: Date: FOR DEPARTM NT SF ONLY G Application Accepted by 'I Area _Q _ ❑ 5tk 466-5781 Lodi 369-3621 Additional Comments: Pit or Grout Inspection b Date /1_ - Date ,.a ° Manteca'823-7104 �` L Tracy 835-6385 Final Inspection by � - Applicant - Return all copies to:� Envi onmental Health 11 Permit/ 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT 'CUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ., INTO i 10182 5U0 EH 13-24 REV. 10/82 14-26 '1