84-892 - Laserfiche WebLink

Home Browse Search

S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466.6781 DATE ISSUED �et�� PERMIT EXPIRES 1 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 far well/pump and the Rules and Regulations.Of the San Joaquin Local Health District. . Subdivision Name Job Address Address 5,� Phone 4 � �— Owner's Name M,04 Phone p� License.No. Contractor's Name ��••��? �^� L� M� NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP WORK: OTHER PUMP INSTALLATION SYSTEM REPAIR ❑ LJ PROP. LINE SEWER LINES DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL AGRICULTURE M� PITS/SUMPS FOUNDATION CULTURE WELL � � �f — (f1 CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL PR08LEM AREA /l L U 'Bottom (]Manteca Dia. of Well Excavation - 1J Industrial o' Dia. of Well Casing Domestic/Private Trac ravel Pack ❑ y ' Delta ✓G ❑ Public ❑Other ❑ Type of Casing /Q ' 'A " Eastern «6 --� pprox""" '❑ Specifications irrigation ! E F-1 Cathodic Protection Depth Depth of Grout Seal Geophysical * Type of Grout j ❑Other I Surface Seal Installed by Fr, H.P. Z State Work Done Repair Work Done Type of Pump Sealing Material (top 50') Well Destruction F-1Well'Diameter, 3 Depth Filler Matenlal (Below 50') } �'REPA'IR/ADDITION i[J (No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK: NEW .INSTALLATION ❑4� � available within 200 feet.) 3 � Installation will serve:•. Residence Commercial Other Numberiof bedrooms i Lot size Number of living units: Water table depth s �� Character of soil to a depth of� feet: No. Compartments Capacity SEPTIC TANK ❑ Type/Mfg s i Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg : Property Line �Distanee to nearest:—Well_ Foundation SEWAGE SYSTEM � , DESTRUCTION i Total length/size LEACHING LINE (J �No. &,Length of lines Property Line FILTER BED ❑ + Foundation }Distantce to nearest: Well I t ,..._ ,Size I Number } SEEPAGE PITS ❑'iDeptli�^ Property Line Distance to nearest: Well Foundation i h SUMPS DISPOSAL PONDS ❑ k� be done in accordance with San Joaquin county I hereby certify that I h prepared this application and that the work will S ordinances, state laws, no les and regulations of the San Joaquin Local Health that District.rformance of the work for which this Home owner or licensed gent s signature Certifies the following: permit is issued, 1 s all employ any person in such manner as to become subject to workman compensation laws of California. Contractor's hiring r su tracting s nns re jertifies the following: "I certiation fy that ,n the performance of the work for which of California." this permit is issu d, hal emp o L r pections. Complete dr i on reverse side. 7 Title: The applicant mu c f r r pate: Signed X Ci �q DEPARTMENT Lye ONLY r >�,Stk 466-6781 Application Accepted by Lodi 369-3621 Additional Comments: - / J Manteca 823-7104 �� Date Pit Grout spection by Date Y ❑ Tracy 835-6385 Fina201 l nspection by Applicant - Return all copies to: Environment Health Permit/Services 1601 L. azelton Ave., P.O. Box 2009, St k., CR 95 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO � �P, ! -14 W Il 10/82 500 EH 13-24 REV. 10/82 14-26