83-559 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERIMIT SAN JOAQUi', LOCAL HEALTH DISTRICT 1501 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. 93- S Telephone (209) 466-6781 GATE ISSUED G-+7--g3 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 com iance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulation f th S uin�pLo�c�al Health District. ,lob Address bdivision Name r Owner's Name Address rN,�> Phone. `,, Contractor's Na License No. 1?6 pap Phone TYPE OF WELL/PUMP WORK; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom [] Manteca Dia. of Well Excavation LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing L Irrigation Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal .� ❑Geophysical ,Type of Grout ❑1 0ther Surface Seal installed by Repair Work Done EJ Type of Pump H.P. State Work Done ¢ 1 Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION — 'REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 91 available within 200 feet.) Installation will serve: Residence Commercial Other r, Number of living units: _[_ Number of bedrooms f_ _ Lot size '� Character of soil to a depth of 3 feet: 239&AWater table depth SEPTIC TANK Type/Mfg Capacity /2 to No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method'of Disposal SEWAGE SYST'1:M ❑ Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines TD Total length/size p FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 171 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 fallowing: "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 workmant 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, I shall employ persons subject to workman's compensation laws of California." The applicant m t call for all e fired inspections. Complete drawing on reverse side. Signed X . Title: Date: / 7/ Application Accepted by F DEPARTMENT USF ONLY� [� Area _ ❑ Stk Additional Comments: Q Lodi 369-3621 .yr, Pit or Grout Inspection by Date Manteca 823-7104 LQ i Z Date Final Inspection by �� L7 Tr y 835-6385 40 Applicant - Return all copies t Environmental ealth Permit/Services 1fi0I E. Hazelton Ave., P.O2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE c7PERMIT N0. f LH 13-24 REV. 10/82 �G(C i.�C�i 10/82 5CO 14-26