83-1377 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT '7 i 1601 E: HAZELTON AVE., STOCKTON, CAPERMIT N0. ��I I Telephone (209)466-6781 li1.2 DATE�ISSUED �'- aJ 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 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 4, Vg9 Il/41_,0_ oeo i`t "' ` Subdivision Name- Owner's Name -"-. I7A- � J �� Address Phone ` Contractor's Name g!!2g �/?/,rl_y� -SO Kf License No. :Z ,3 413 Phone ,(�3, 0 X77/ TYPE OF WELL/PUMP WORK: NEW.WELL� L WELL REPLACEMENT` Q; '.DESTRUCTION'❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Opens Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing 1 Public Other Deo � ❑ ❑ ❑ l tType-of_Casing ❑ Irrigation Approx. [] Eastern Specifications Cathodic Protection Depth t F-11dPtit Depth of Grout Seal I ❑Geophysical x Type ofGrout ❑Other Surface"Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction El Well Diameter- Sealing Material (top 50') Depth !# Filler Material (Below.50') TYPE Of SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is 4— available within 200 feet.) Installation will serve: Residence Commercial Other =1.► Number of living units: .1 Number of bedrooms Lot size .1. A Cit GS Character of soil to a depth of13 feet: t,., i Water table depth O Capacity a Q No. Compartments SEPTIC TANK FmType/Mfg _�A��Y.�/`�� _� � , PKG. TREATMENT PLT. ❑ Type/Mfg '_.' 1 Capacity Method of Disposal SEWAGE SYSTEM Distance�to,nearest: Wel-1-Z-�0 poundation =fid"� Property Line DESTRUCTION ❑ D - - f` LEACHING LINE ❑ No. & Length of lines / _ Total length/size 7.4 FILTER BED ❑ Distance to.nearest: Wel'1' /��r Foundation cS41 Property Line /0 SEEPAGE PITS [] Depth a Size " T _.=rNumber r SUMPS ❑ Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑I ~ 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 Wthe San Joaquin Lgcal-Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this p 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 applica must call for all re fired inspection' Completeaw' o�a side. ` Signed X Title: Date: 2 3 ,.y ❑ Application Accepted by Area � Stk 466-6781 r ❑ Lodi 369-3621 Additional-comments. - Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by DateTracy 835-6385 Applicant - Return all copies toy Environ tal;Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # FEEBASE AMOUNT 'DUE AMOUNT REMITTED RECEIVED BY DATE " PERMIT NO. INFO -40 1 , 0, `` EH 13-24 REV. 10/8210/62 500 14-26 L97