84-39 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN 3OAQLiN LOCAL HFALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 1 Telephone (209) 466-67$1 DATE ISSUEO� PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 Health District. Job Address S3 969' I�osT��- gyp[ Tj iyGy - Subdivision Name Owner's Name 49--iYnV1d Address -73 y'651 J1v',V7rY Phone Contractor's Name 0-F, License No. Phone TYPE OF WELL/PUMP WORK: NEL! WELL �. WELL REPLACEMENT L] DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER FJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS }� Industrial Bottom_ Open Manteca Dia, of Well Excavation - _ U Domestic/Private Gravel Pack Tracy Dia, of Wefl Ca fng— 17 Public F-1 Other Delta Type of Casing F, Irrigation Approx., Eastern ❑ Cathodic Protection Depth ,Specifications Depth of Grout Seal Geophysical Type of Grout Other ' r Surface 'Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done ZJ�} Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) -� Installation will serve: Residence _Commercial Other _ Number of living units: 1 Number of-bedrooms --- Lot size rY�i c Yt3 Character of soil to a depth of 3 feet: Ac,O1y Water table depth SEPTIC TANK Type/Mfg A3,e C/i_V T Capacity /60 D 6AZ No. Compartments x PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Ei Distance to nearest: Well /00 ' Foundation iy' Property Line " S- DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well /A � Foundation ;a x' Property Line J-0 ' SEEPAGE PITS Depth Size Number SUMPS �� istanee_to_nearest: Well Foundation. _ Property Line - DISPOSAL PONDS 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. Homeowner 6 I icensed agent's signature certifies the following: "I certify that in the performance of the work far which this permit is issded, I shall not employ any person in such manner as to become subject to warkman� 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 mus call fo all required inspections. Complete drawing on reverse side. Signed X Title: Date: / S� R TMENT USE ONLY Application Accepted by Area 7--- [] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date IC] Manteca 823-7104 Final Inspection by //W Date FES -94 04 Tracy 835-63$5 Applicant - Return all copies to: Enviro tal Health Permit/Services 1601 E. Ha2eltor Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BYE:DATE ;RM��INFO S?I� -EH 13-24 REV. 10/82 [u1 !! 10/82 50C 14-26