84-622 - Laserfiche WebLink

Home Browse Search

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 DATE ISSUED (Complete in Triplicate) f 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)nRegulations (� the San Joaquin Local Health District, Job Address i tnAfft,*CA RABA()ubdivision Name Owner's Name 04 A WSS QR'"" 14+11 Address Phone Contractor's Name I/h 2C 2G�Le License Ne. 3`?/ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U I PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE$ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s � 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom [] Manteca Diaof 'Well Excavation 8 �' 4 U Domestic/Private Gravel Pack Tracy Dia. of-Well Casing f I-7 Public F-1 Other Del to Type of Casing Lj'Irrigation Approx. Eastern Specifications Cathodic Protection Depth ` v Depth of Grout Seal LJ Geophysical Type of Grout U Other Surface Seal Installed by a ReState Work Done I Repa�r Work Done � Type of Pump H.P. � �WellfDestruction LJ Well Diameter Sealing Material (top 50') tt Depth Filler Material (Below 50') r� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public'sewer is available within 200 feet.-) Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms Lot size 7 ICF YWater table depth Character of soil to a depth of 3 feet:' 4ru� , SEPTIC TANK Type/Mfg Capacity. No. Compartments PKGI. TREATMENT PLT. 0 Type/Mfg Capacity Method of Disposal E SEWAGE SYSTEMr Distance�;to near-este�lJe]_1, F.oundatian Property Line ? DESTRUCTION fQ 1 Total length/size LEACHING LINE �J No. & Length of lines_ , FILTER BED 1-11Distance to nearest: Well _�0� Foundation ' A Property Line a .Number I SEEPAGE PITS # �j Depth --t Size � SUMPS r-"" — E undati n Property Line i U Distance to nearest:_Well—._--- p DISPOSAL PONDS PO NDS CI 4 I � i v I Hereby certify that I have prepa'Fed this application and that the work will be done in accordance with San Joaquin county ord.inances,istate laws;k'"and'.rules`and regulations of the San Joaquin Local. Health District, �'� .�wbrl, Home owner 6r licensed agent`s signature certifies the following.:.«"I-c&tify_thatin the per ormance of the work for whieh this permit is issued, I shall not employ ahy person in_such mariner as to become subject to workman compensation Laws of California." of the work Contractor's hiring or sub-contrac.ting.si.gnature certifies the following:- "I certify that in the performance� or which this permit is issued, .I-sha•I1�employ persons sub'3ect'ito,iworkman's compensation laws of-California.", I The•applican"tit call for all requi ed inspections. Complete drawintg� on reverse side ` .� Date: Signed X � 1(Jv+1� � � �`� Title: � F FOR E ARTMENTr.USE ONLY, 3 P # Area -EJ Stk 466=5781`- '`� t Application Accepted by e �fV I � i [ Lodi 369-3621 r Additional Comments: t y Y, N Pit or Grout Inspection bDate + Manteca 823-7104, -� Final'�Ih s°p ecti on—by°°�� 1 Date ❑ Tracy 835-6385 9 Applicant - Return all copies to: Environmental`Health Permit/Services ab01 Ha?el on Ave. P.O. Box 20D9, St k., ICA ,5201 BASE AMOUNT DUE AMOUNT REMITTED i RECEIVED BY DATE PERMIT NO. ' � LE1 - � �- 10/32 500 LH 13-24 REV. 10/82 14-26