84-396 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR,PERMii SAN JOAQL'iil LOCAL HEALTH DISTRICT PERMIT N0, a 1601 E. HAZELT014 AVE., STOCKTON, CA i Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k. (Complete.in Trip]icate) ^ Application'i's hereby made to the an Joaquin Local`Health District fora 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 Re ulations.of ,the,San Joaquin Local. Health District. Job AddressS ` � V Subdivision Name Phone Owner`s Name u � Address. U Contractor's Name tLLXN" F UIP License No. CsO Phone 161--767 TYPE OF WELL/PUMP WORK: NEW WELL . Nf WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ �- �'w _ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE5 � ,rt, '= FOUNDATION AGRICULTURE WELL + OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open'Bottom ❑ Manteca Dia,` of Well Excavation [ : Dia! of Well Casing r a ❑ DomesticiPrivate ❑ Gravel Pack ❑Tracy • i ❑ Puhlicg �Other E]Delta Type of Casing �^ Eastern r f7lIrrigation Approx. ❑ Specifications 71Cath;dic •Protection Depth Depth of Grout Seal sb I❑Geophysical p Type of Grout ` ❑Other = tSurface Seal Installed by Repair Work Done-❑ Type of Pump i; H.P. State Work Done 1 Well Destruction L f Well Diameter, 9. Sealing Material (top. 501) } Depth F ' Fi1 er,Material (Below 509 i TYPE OF�S�PTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITfON-' ❑" (Na septic tank or seepage pit permi£ted if public sewer is i r F available within 200 feet.) installation will serve: Resifdence 'Co4erctial i Other Number of 11 i'i_I Tunits: �. ber ofwbedrodms =� Eat size , Character fnf`soil to a depth of,73 feet: Water table depth t Ca acity No. Compartments SEPTIC TANKS ❑ Type/Mfg h P PKG. TREATMENT PLT, U Type/'M'fg 1 Kg * Capacity Method of Disposal I Property Line. ` SEWAGE SYSTEM Distance to nearest: Well' Foundatidn P r# DESTRUCTION .1 F' 3 LEACHING LINE ❑} No. &" Length of lines 1 It length size EE z t Property Line FILTER BED ( ❑ Distance to rearest: Well Foundatien: d ; ' i SEEPAGE;PITS � F-1Depthe i F ` ,Size .-Number 1 : Well- Foundation, Property Line Distance to nearest SUMPS 5 LJ f y � DISPOSAL PONDS ❑ 't 11 �!�� Is� '� /1 � �, 'l� F v I/� I I herebyk,ce`rtify that I have prepared this application and that the work will be done in accordance with San Joaquin county r ordinances.,Istate laws,�,and:rules and regulations of the San,Joaquin Local Health District. r Nome awnei "r licensed agent's s.i_gnature certifies the fol lowing:;"I -certify that in the per of the work for which this permit s ued, I shall hot employ any person in such manner as'to .become subject to workman�compensation laws of California." permConttc�tIn ing or ub-contracti signature certifies the following: "I certify that in the performance of the work for which this pea ssued, I shal.l4em erso subject to workman's compensation laws of California." The app'lst cal f r al}} eq in ections, Complete.,(d''rapwin `on rever s d �`Title r' Date:Signed 'X '�`' FOR DE TMENT ON ) ✓i ❑ r # Area 5tk 466-6781 ;Application Acc d tom", I , 1 t { E ❑ Lodi 369-3621 ?Additional Comments: Manteca 823-7104 v 3 Pit or Grout Inspectio b.y Date /`._�� .- Tracy 835-6385 ; a Inspection by Date ' ❑ Applicant -Return all eopies,to: Environmental Health Permit/Servicls 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 Fin t: F'EF l Z AMOUNT DUE T : AMOUNT REMITTED RECEIVED BY DATE p PERM�-i NO. INFO 1 LF)I ^�q d�' , ; I rC'u 0 lO/e2 500 EH 13-}24 [REV. 10/82 �/� G VYL `: 0 �,1/U +1 J+� E �y�, IV_L� Q 7 nSpQ.&4 On , 14}26 � pG • . �� / J G�.1lt T'i ck