83-1219 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HE7;LTH DiSTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 3 r � Telephone (209) 466-6781 PERMIT NO, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) Application is here 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,Regul.ations of.-the.5an JOdQUl n Local Hea h District. Job Address /.� Subdivision Name Owner's Name f .� {. W j Address /7/` J!A f jil` � t Phone Contractor's Name61!5{�nf��kl►o� License N0. ® Phone t _ TYPE OF WELL/PUMP WORK: NEW WELL Q WELL,REPLACEMENT ❑� FDESTRUCTIION❑ P; .�- S PUMP'"INSTALLATION•-0_.. r$Y5T£M`RkPA IR "-f=� w `4OT.HER-{Jao �j- •- ----�+-,� DISTANCE_TO NEAREST.:. SEPTIC,TANK "w _ _ _,SEWER LINES DISPOSAL FLO. . PROP. LINE_ = FOUNDATION . AGRICULTURE WELL OTHER WELL PITS/SUMPS W INTENDED USE ` "TYPE OF*WELL="P,RCBLEM AREA CONSTRUCTION SPECIFICATIONS J'Industrial U Open Bottom ❑Manteca Dia. of,Well Excavation ( LJDomestic/Private Gravel Pack Tracy Dia. of Wehl Casing ❑ Public r_1 OtherQ Delta 5 Ne, ` irrigation t Type of Casing lam' 9 , Approx. Eastern - - ## w �L Specifications ~ Cathodic Protection "" .,Depth d i t Geophysical""" Depth of Grant Seal Type,,of Grot't Other + .+ / # Surface Seal Installed by _ ' e Repair Work Done Type of Pump H.P.¢ State Work Done Well Destruction U Well Diameter Se-_aIing Material. (top 50'}4 _ $wf Depth Filler Material (Below 50') . •� ,� .� _ ��..+ woe I TYPE OF SEPTIC WORK: NEW INSTALLATION (No septacgtank or seepage pit �ermitt)ed if public sewer is } available',within 200 feet.) lnstailation w'Tl seYwe. -esi4.,VwaX�CoZlmercial� %, Other ' t 1 } E'y.n.•. moi-. — ,� , I Number of Ivi,ng units: i' r ��Nnmber of bedrooms �%�" \ —Lots + � � T�„� -� f Character of soil to a depth of 3 feet '� " `s .;. Mater- table d,e th `PWC TANK ❑j Type/Mfg tGapacity 12&[�' No. Compartments # t [x.y - LATMEtNT PLT. Type/Mfg Capacity Method of Disposal"`.: SEWAGE b-STEM o Distance to nearest: Wel +. Foundation.. Property Line *� L DESTRUCTION \ 1 , _ _ 'a - �*: �� i '%t EACHING LINE No. & Length 07 0f Tines Total length/Tize R ;0. _ .t FILTER BED Distance to nearest: Well .� Foundation Property Line *� $EEPAGE-iPITSi e ' ' + i ��i Depth R - 5i ie ��. Number rr SUMPS'' X i-Distance to nearest: WeII7 Foundation - Property Line DISPOSAL PONDS ❑ �� f.� �7�5 _ t, Z4 E '� I hereby certify that I have prepared this application and that the work will be done in acco d&e with San Joaquin county Cordinances, 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, I shall not employ any person in such manner as to become subject to worknan� 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 i s d, I shall employ persons subject to workman's compensation laws of California." The applicant ll for 1 re ire inspections. Complete dr in o verse side. Y Signed X Title: Date: ' ti i n FOR DEPARTMENT USE ONLY t1_1Z I I I - Application Accepted by C�t�� #?Area.� , z C ❑ Stk + 466-6181 t Additional Comments: Wt 31 i"4i` '"*❑ Lodi 369-3621 -1� mv - ' Pit or Grout Inspection by Date K•Manteca_,023-7di0.4 Final inspection by AL { Date Tracy;: 835-6385. Applicant - Return all copies to: Env'ironme Hearth IP,ermia/Sexvic s 4601 +'Hazeltom.Rve., P.O. Bax 2009, .Stk.,E.CA 95201 FEE BASE AMOUNT DUE AMOUNT .REMITTED RECEIVED BY DATE,4?�" PCRMIT..NO. { ` `Y.t "}. •. t �.' „i +- a.. 10 8 500 7 EH 13-24 -REV.- 1'0/82 i . ,;