SR0082306 - Laserfiche WebLink

Home Browse Search

b k ©z r ,w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DAT [SSU ED pl riplic Application is hermade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, This a plication 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 Joaqu n L al Health District. Job Address Subdivision Name Owner's Name Address. one Q J �Q Contractor's Name ' License No. �� +�� -� 'honelm`� TYPE OF WELL/PUMP WORK: NEWjWELL WELL REPLACEMENT DESTRUCTION Lj PUMP INSTIA1L'_ATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD.1 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAt .CONSTRUCTION SPECIFICATIONS' i [j Industrialp s U Open' Manteca Dia: of Well Excavation ` Cj Domestic/Private Gravel Pack `racy Dia.-of Well Casing 17 Public Other Delta {" Type of'Casing ! LjIrrigation Approx_ Ej Eastern Specifications Cathodic Protection Depth «— Depth,of Grout Seal LJ Geophysical LJ Other � -L Type of Grout Surface Seal Installed by Repair Work Done F] Type of Pwrp H.P. State Work Done r L% Well Destruction (J Well Diameter Sealing 'Material (top 50') Depth /Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION (No septic tank o seepage pit permitted if public sewer is Installation will serve: Residence Commercial Other �jble within 200 feet.) oval Number of living units: Number of bedrooms _ Lot size L f� Character of soil to a depth of'3 feet: Water table depth d SEPTIC TANK Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg. ^ Capacity Method of Disposal SE'WAGE:SYSTEM 1—� Distance to nearest: Well Foundation Property Line ll 1T. DESTRUCTION t ---` LEACHING LINE 'U No. S Length of lines ........... Total length/size FILTER BED Distance to nearest: Well�oar Foundation Property Line SEEPAGE PITS Depth ,Size Number ' SUMPS I-I Distance to nearest: Well Foundation f�! Property Line s� DISPOSAL PONDS ❑ w >' 1 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 rulesland regulations of the San Joaquin Local Health District. a Home owner or licensed agent's signature certifies the following: "I certify that i'n 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 o` Califnrnia." Contractor's hir'ng or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is i sued, I shall employ persons s ' ns. Cact to workman's compensation laws of California." The applica 1 for 1 re 1 ns dr on reverse side. -C/�-� lJX_L+CL I Signed X � tle: Date: R PART T USE ONLY Application Accepted by _ Area d2 Stk 466-6781 Additional Cornrents: /fit Off? (J Lodi 369-3621 Pit or Grout•Inspection by Date lo.'� J Manteca 823-7104 Final Inspection by Date G/G ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601A. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT bUE AMOUNT REM:TTED RECEIVED BY DATE PERMIT 40. ' INFO � Q EH 13-24 REV. 10/82 10/82 500 r 14-25 k