84-710 - Laserfiche WebLink

Home Browse Search

JUN FOR PERMIT �yUN 6 984 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. SM JOAQUIN LOCAL Telephone (209) 466-6781 JjIMTH DIS iCT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED b-�v UE ^g (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 Regula ions of a San 4oaquin Local Health District. Job Address f --3 Subdivision Name Owner's Name 4JWI►TIT. Address Phone Contractor's Name _ License No. Phone Z7 f TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. - PROP.-L-INE- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial [Open Bottom [] Manteca Dia. of Well Excavation mestic/Private Gravel Pack Tracy Dia, of Well Casing ..r 1-1 Public EJ Other ❑ Delta Irri ation Type of Casing U 9 Approx. © Eastern Depth Specifications W Cathodic Protection Depth of Grout Seal W 0 Geophysical 17 Other Type of Grout Surface Seal Installed by Repair Work Done _Type of Pump .0 H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material top 50') _ Depth Filler Material (Below 50') 7<?. TYPE OF SEPTIC WORK: NEW INSTALLATION [JREPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is 1. Installation will serve: Residence _ Commercial _ Other available within 200 feet.) f Number of living units: Number of bedrooms Lot size 'p Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK -F—_- Type/Mfg Capacity r -No�Gompartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal S SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line r DESTRUCTION Cl LEACHING LINE U No. & Length of lines Total length/size FILTER BED F-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ nuu.onnnn.mr un 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, 1 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, I shall employ persons subject to workman's compensation laws of California." The applican st call for a fir d ns a do Complete dra 'n on reverse d Signed X Title: /®wr Date: Application Accepted I OR D NT UjE O-4 4_K rea ( Z ElSStk 466-6781 Additional Comments, 6 p�codi 369-3621 Pit or Grout Inspection by Date �� _Manteca 823-7104 Final Inspection byfi�� _ pate r Tracy 835-6385 _ Applicant - Return all copies to: Environm9 tal Health Permit/Services 1 01 E. Hazeltorymve., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 17 C�l Q V $LA——71 c7 EH 13-24 REV, 10/82 10/82 500 14-26