82-664 - Laserfiche WebLink

Home Browse Search

4 goo, APPLICATION FOR PERMIT t J � 9 SAN J0 QUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. — r Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I 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. . I Job Address ZOO W, MA9 44 A45F. Subdivision ,Name Owner's Name Address Phone Contractor's Name =40yp �� Lf/es®DLicense No. Phone TY PE.OF WELL/PUMP WORK: NEW WELL t, WELL REPLACEMENT;❑ DESTRUCTION.[ .... ...— ; `� ....- y4..rr .�.+.r.. ,.+w PUMP INSTALLATION ❑ SYSTEMREPAIR EJ ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'h! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS"' Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel i Pack ❑ Tracy $ Dia. of Well Casing Public _ ❑Other. ..❑ Delta. '"F pe of`Casing ' Irri ation A rox. Eastern " f LI 9 Depth ❑ Specifications ❑Catkodic Protection P Depth of Grout Seal ❑ Geophysical Type of Grout Other. �, Surface Seal.Installed by Repair Work Done ❑. Type of Pump N.P. State Work Done Well Destr'tion ❑ Well Diameter 1 Sealing Material (top 50') Depth Filler Material (Below 50') i 0 TYPE OF SEPTIC WORK.. NEW INSTALLATION REPAIR/ADDITION (No,septic,tank�or seepage pit permitted if public sewer is C I a ) available within 200 feet.) Installation will serve: Residence X Commercial _ Other Number of living urn _its: Number of bedrooms 3. .__ Lot size AC,�ES Character of soil tb,a depth of 3-feet: SAW Water table depth J TSD SEPTIC TANK �j Type%Mfg /16i/nO E, Pd L_____ Capacity IZpO No. Compartments Z PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal Distance Lto nearest: Well Foundation /0 Property Line LEACHING LINE & Length of lines Total length/size r FILTER BED ❑ Dist nce to+nearest: Well 100 Foundation oW Property Line r SEEPAGE PITS Dept6l. _. .w. —._--,_Size_—, Jiumber„ SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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's1,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.inrsuch:_mannerras._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 applicant must 11 for all'required inspections. Complete drawing on reverse side. Signed X Title: Date: wAEPARTMENT USE ONLY . Application Accepted by { FOR DAreas Stk 466-6781 i ti Additional Comments: /� �""" ❑ Lodi 369-3621 s. ► Pit or Grout Inspection by 52 Date Manteca 823-7104 Final Inspection by Date t � ❑ Tracy 835-6385 3 Applicant - Return all copies to: �Envi nm ntal Health Permit/Services 16 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 { 14-26 �/