83-1073 - Laserfiche WebLink

Home Browse Search

c `r APPLICATION FOR PERMIT SAN JCAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 DATE ISSUED 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 compliance with San Joaquin Co rty Ordinance No, 549 for sewage or No. 1862 for well/pump and the Rules a,4`R.e`gulationsarof the San Jooa�uin Local Health tri Job Address 1� [+��Sd/� r� /TW �+� ublUi b a Na nye Owner's Name f� A- Addre � � � � Phone Contractor's Name /7 Qale4- COs - License No. Phone.S TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS UA r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation W U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing ❑ Public CJ Other ❑ Delta 71 irrigation Approx. ❑ Eastern Type of Casing ❑ Cathodic Protection Depth Specifications O 17 Geophysical 0epth of Grout Seal ❑Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION kR.IPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence mmercial Other Number of living units: Al-_ Number of bedrooms _ Lot size Character of soil to a depth of 3 feet:_ /✓ _ Water table depth SEPTIC TANK ❑ Type/Mfg 4'7N Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION 44 LEACHING LINE No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation f Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance 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. 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 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 applic ust call f? 1 required ins ections. Complete drawing on rever side. 5j' Signe /��/ Title: Date: / ��3 F DEP TMEN E ONLY Application Accepted Area QG ❑ 5tk 466-6781 Additional Comments: ❑ Lodi 369-3521 Pit or Grout Inspecti by Date I�Manteca 823-7104 Final inspection by � Date N �❑ Tracy 835-6385 Applicant - Return all copies o: Ervironm al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 540S7 73-10?3 EH 13-24 REV. 10/82 10/82 500 14-26