83-981 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUE017AD 10 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.r 549 for sewage or No. 1862 for well/pump and the Rules and Regulatio s of the San Joaquin Local Health District, Job Address6� Owner's Name ' Address Phone License No. Phone Contractor's Name l TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ ` -- "`oQ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION P AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS industrial 0 en Bottom ❑Manteca Dia. of Well Excavation- _J Dia. of Well Casing #,y ❑ Domestic/Private ❑Gravel Pack ❑Tracy ' ' 17 Public ❑Otherf ❑ Delta Type of Casing Irrigation Approx. ❑Eastern Specifications r ❑Cathodic Protection Depth , a Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by ; Repair Work Done Type of Pum •P• State Work Done r Well Destruction ❑ Well Diameter Sealing Materi 1 {top 501) r + Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIRlADDITiON ❑ (No septic tank or seepage pit permitted if available-withinu200cfeet.) is Installation will serve: Residence Commercial Other 0Number of living units: Number of bedrooms Lot size , (�( Water table depth Character of soil to a depth of 3 feet: _ +-. Capacity No Compartments SEPTIC TANK F-1 Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Foundation' Property Line SEWAGE SYSTEM Cl Di stance;to nearest: Well `�' _ DESTRUCTION No. & Len th of lines Total length/size LEACHING LINE U 9 FILTER BED ❑ Distance to nearest: Well Foundation T Property Line SEEPAGE PITS ❑ Depth 1 Size Number'. Distance to nearest: Well Foundation 1: Property Line SUMPS �I � DISPOSAL PONDS ❑ Q 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county rn " ordinances, state laws, and rules°and regulations of the San Joaquin Local Health District. l . Home owner or licensed agent's signature ctifies thesucfollowing:manner as to certifybcomesthj at intthe pe nrfo�compensatance of i+onwf laws of California." '. permit is issued, I shall not employ any person Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work.,for whit this permit is issued, I shall employ persons subject to workman:s compensation laws of California." �7 The applicant m s call for all required inspections. Complete drawing on reverse side. Date: -93, Signe�� ! e .w TitlQV e FDR DEPARTMENT USE ONLY` ❑ Stk 466-6781 Application Accepted by' Area �tj dt�/ Lodi 369-3621 Additional Comments: ❑ Manteca 823-7104 - Pit or Grout Inspectio by Date Final Inspection by Date 3 ❑ Tracy 835-6385 Applicant - Return all copies oi. EnviroA lth Permit/Services 16D E. azelton Ave., P.O. Box 2009, Stk., CA 45201 t PERMIT NO. FEE BASE AMOUNT IDUE AMOUNT REMITTED RECEIVED BY DATE INFO �� 13012-- �� 10/82 500 EH 13-24 REV, 10/82 14-26