84-843 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERIM17 ZI (� SAN JOAQLIN LOCAL HEALTH DISTRICT jr 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. T Telephone (209) 466-5781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate} Application is hereby made to the Sar 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 nd// Regulations of the San Joaquin Local Health District, y Job Address IRCIP O'f k �. Subdivision Name Owner's Name T� �- Address Phone � y^ Contractor's Name / 11W License No. Phone 45F )—77 TYPE OF WELL/PUMP WORK: ?LL WELL REPLACEMENT L] DESTRUCTION U OTHER PUMP I�NEION SYSTEM REPAIR j 11 U r" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL P[T5/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� I J Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private Gravel Pack 0 racy Dia. of We11 Casing _ 1 Public Mother El Delta Type of Casing PI/ 6:_ 4 7 V Irrigation Approx. L] Eastern Specifications Cathodic Protection p De th , Depth of Grout Seal Geophysicalr Type of Grout 1 LI 0 Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') — �! Depth il Filler Material (Below 50') } rth TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION j� (No septic tank or seepage pit permitted if public sewer is 1 ' . available within 200 feet.) l Installation will serve: Residence _ Commercial Other M Number of living units: Number of bedrooms Lot size r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK FJ Type/Mfg Capacity, No. Compartments V) PKG. TREATMENT PLT. [J Type/Mfg Capacity,.¢ Method�of Disposal SEWAGE SYSTEM ci Distance to nearest: WellFoundation ` �Pro ert P y Line - DESTRUCTION LEACHING LINE U No. & Length of lines :" Total-length/size C I- Pro erty Line FILTER BED Distance to nearest: Well Foundation P m SEEPAGE PITS Depth" `�. r Size Number SUMPS / L� Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS , 4 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 k permit is issued, I shall not employ any person in such manner as to become subject to workmanK.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, 1 shall _employ persons subject to workman's compensation laws of California." The applican t cal for 11 required inspections. Complete drawing�on reverse side. �i I Signed X Title: �y Date: f/ fff PARTMENT USE Y �� 466-6781 Application Accepted by Area Stk Additional Comments. Lodi 369-3621 anteca 823-7104 Pit or Grout Inspection by r Date r Final Inspection by ► Date racy 835-6385 II Applicant --Return all copies to: nvironmertal Health- Permit/Services 16 1 E. Ha elton Ave., P.O. Box 2009, Stk., CA. 95201.--- riN BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMGIT NO. L j `� n f. lit) 7-0 4 '7 1 IJ VI 10/82 500 i EH 13-24 REV. 10/82 14-26