83-575 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT } SAN JOAQUiN LOCAL HEALTH DISTRICT JUN2 7 1, 53 4 1601 F. HAZELTON AVE., STOCKTON,�Ch PERMIT N0. O 3 � 7, Telephone (209) 466-6781 ' f1�I JOAQUIN LOCAL DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUEJEALTH DISTRICT (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 ealth District. Job Address_23Q31 L. A,-e_ Subdivision Name Owner's Name T S• PajaVAddress /5i + Phone 8ff 76,V Contractor's Name % License No. 2eLJFd10 Phone 42�?9-2,2427 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL. REPLACEMENT ❑ DESTRUCTION ❑ h PUMP INSTALLATION . ❑ SYSTEM REPAIR OTHER ❑ p� DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _S Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation` 1 h Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other, ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal 0 Geophysical Other Type of Grout Surface Seal Installed by 5 Repair Work Done Type of PumpH.P. State Work Done �/1f-? U i+�� e=# r U Well Destruction ❑ Well Diameter 11 Sealing Material (top 50') _ Depth Filler Material (Below 50') ail TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION EJ_ (No septic tank or seepage pit permitted if public sewer is -� - - Installation will serve: Residence Commercial Other available within 200 feet.) I. - Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 qfeet: Water table depth SEPTIC TANK ❑ Type/Mfg '+ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION - E 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance 'to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number SUMPS F1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s 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's_ubject to workman ls 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." F The applican ust 11 fo a equired inspections. Complete drawing on reverse side. i Signed K Title: Date: FO ARTMENT USE ONLY Application Accepted by Area _ 11 ❑ Std 466-6781 ❑ L di 369-3621 Additional Comments: Pit or Grout Inspection\b�- Date $23-7104 Final Inspection by ._ Date `�� [❑ Tracy 835-6385 Applicant - _Return all copies to: Environmene� Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE „ PERMIT NO.- INFO 1 f 1 � �,y� (� �r �3 `�� EH 13-24 REV. 10/82 10/82 500 ; 14-26