83-1119 - Laserfiche WebLink

Home Browse Search

r } Vol APPLICATION FOR PERMIT AOUiN LOCAL HEALTH DI3 SAN JO 1601 E. HAZELTON AVE., STOCKTON, � O C_ r` 1,983 PERMIT NO. Telephone (209) 466-6781 DATE ISSUED L PERMIT EXPIRES 1 YEAR FROM DATE ISSUE IOAQUIN LOCAL (Complete in Triplicate) E-JEALTH USTkICT 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. Subdivision Name Job Address S, /Lt L c� Address P,}-r% Phone Owner's Name S7 �PU�2 ��Q�� Phone ;-22-r�7 Contractor's Name t u I�-J. License No. ly TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION W PUMP INSTALLATION SYSTEM REPAIR OTHER U l DISPOSAL FLD. PROP. LINE ! DISTANCE TO NEAREST:•SEPTiC TANK SEWER LINES OTHER WELL PITS/SUMPS FOUNDATION 1 AGRICULTURE WELL J INTENDED USE TYPO OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑Manteca " Dia. of Well Excavation 1 Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public F- OtherOther L] ' Type of Casing _ V Irrigation Approx. Eastern Specifications ❑Cathodic Protection 1 Depth Depth of Grout Seal Geophysical Type of Grout LJ Other Surface Seal Installed by t H.P. �� State Work Done e' e u d Repair Work Done Type of Pump ' Well Destruction L} Well Diameter Sealing Material (top 50') d Depth Filler Material {Below 50') ' REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTA�ATION �� U available within 200 feet.) Installation will server ResiIdence _ Commercial Other 1 n Number of living units: F Number of bedrooms Lot size V� Character of soil to a depth of 3 feet: Water table depth Capacity No. Compartments SEPTIC TANK � Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Foundation .Property Line SEWAGE SYSTEM � Distance to nearest: Well e DESTRUCTION No. & Len th of lines Total length/size LEACHING LINE N LJ � 9 Property Line FILTER BED Distance to nearest: Well Foundation Depth' Size Number SEEPAGE PITS ❑ P t Property Line SUMPS U Distance to nearest: Well Foundation DISPOSAL PONDS t 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 rul'es and regulations of the San Joaquin Local Health District. Home owner, or licensed agent'stsignature certifies the following: "I certify that in the performance of the work far which this i employ any person in such manner as to become subject to workman compensatio permit is issued, I shall not n 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 'empl y persons subject to workman's.compensation laws of California." l The applican m st call f 11 Auired inspections. Complete drawing on reverse side. Date:/ S t Title: p Signed Xw FO DEPA N SE ONLY � �'..� f� � Stk 466-6781 Application Accepted by rea �----- E] Lo 369-3621 Additional Comments: Manteca 823-7104 Pit or Grout Inspection b Date [� Final Inspection by Date = ❑ Tracy 835-6385 01 Applicant - Return all copies to: "Environment ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 952 DATE PERMIT N0. FLFEE -BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 10/82 500 EH 13-24 REV. 10/82 ealzt �] 1 14-26 ! !