83-902 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR.PERMIT SAN JOAQUIN LUCAL HEALTH DISTRICT O 1601 E. HAZELTON AVE.,' STOCKTON, CA PERMIT NO. k Telephone (209) 466-6781 ? DATE ISSUED �? PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 2 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. o;� felJoaqu}r L�� Health istrict. Sob Addresses T /� Subdivision Name Nv Owner's Name ok te r' S {161�dress Phone Contractor's Name V License No..l�f06"3�" Phone �7T TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION;?� 1 V",`1 PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS173 Industrial U Open Bottom Manteca Dia. of Well Excavation jam' 1J Domestic/Private F-1 Grave; Pack ❑ Tracy Dia. of Well Casing Public Other Delta Type of Casing Irrigation Approxi Eastern Specifications LI Cathodic Protection Depth Depth of Grout Seal 11 Geophysical Type of Grout U Other Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter '/--2 01 — Sealing Material (top 50') — © a Depth � Z/� SG f Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is r available within 200 feet.) Installation will serve: Residence _ Commercial Other } Number of living units: Lot of bedrooms Lat size 1, Character of soil to a depth of.f3 feet: Water table"depth SEPTIC TANK Type/Mfg Capacity No. Compartments is PKG. TREATMENT PLT. F-1 Type/Mfg,: Capacity Method of Disposal E Foundation Property Line ! r SEWAGE SYSTEM ❑ Distance.to nearest: Well k DESTRUCTION ' { i h/sze J 1 LEACHING LINE U No. &Length of lines Total lengt FILTER BED Distant'Ito nearest: Well Foundation Property Line 4J SEEPAGE PITS Depth ' Size Number ] SUMPS Distance'to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San 13oaquin 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 permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of Californiac Contractor's hiring or sub-contracting signature certifies the following: "1 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." j The applieant must all for all required inspections. Complete drawing on reverse side. , ' Title: Q � Date: �a Signed x - FO )' ENT US ZLY �l Application Rccepted by Area G pC - Stk t� 6-6781 Lodi 364-3621 Additional Comments: # Manteca 823-7104 Pit or Grout Inspection hy� Date � Final Inspection by Date y�� 3 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,. Stk., CA 95 201 FEE BASE AMOUNT :DUE AMOUNT REMITTED .�R/ECEIVED BY DATE PERMIT NO. INFO L i,r1�1 ! ► �� 10/82 500 � EH 13-24 REV. 10/82 � r r-,^d'.J/�' 14-26