83-573 - Laserfiche WebLink

Home Browse Search

k e+ APPLICATION FOR PERM L SAN JOAQUiN LOCA! ,F- ,I :ISTRICT JUN 2 11983 � �p 1601 E. HAZELTON AVE., STOCKTON, A PERMIT NO. Telephone (209) 466-6781 SSAN Ji1AQUN LOCAL DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUMEALTH DISTRICT (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. Job Address L Subdivision�Name Owner's Name /t. Address > Ll 1 XrL Phone Contractor's Name fv A_/ License No. �Q/,0 phone247 TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION s PUMP INSTALLATION SYSTEM REPAIR OTHER V E14 �E�Q64/1'zio,-�-�� d1 ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1111 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V ; E) Industrial U Open Bottom 7 Manteca Dia, of Well Excavation VJ Domestic/Pr•i-va-te..-..,. -El Gra Vel: Pack 0 Tracy Dia. of Well Casing ? -4 Public [—I Other L Delta Type.of-�Casing {� irrigation F Approx. E] Eastern Cathodic Protection . Depth Specifications r Depth of Grout Seal Geophysical Type of Grout f F-1Other ' Surface Seal Installed by r Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material~(top_�50',) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK:-. NEW;INSTALLATION,Lj REPAIR/ADDITION J (No septic tar kfcrjseepage 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 - Character%of-'soil-to`a:deptl of 3 feet:, _:Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Type/Mfg , Capacity Method of Disposal I _SEWAGEaSYSTEM' Distahce�`Onearest: Well Foundation Property Line T DESTRUCTION BLEACHING LINE; jJ Na: & Length of ,lines Total length/size -- ^- ^- FILTER BED Distance to nearest: Well Foundation PropertyLine J +, SEEPAGE PITS Cj Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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'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 becdme,subjec`t�to workman 1s compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I"cer"tify that in the-performance of the work for which q this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applican st al] g al equired inspections, Complete drawing on reverse side. ' Signed X Title: Date: FO RTMENT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspectio Date Manteca 823-7104 b Final Inspection by Date L7 Tracy 835-6385 Applicant - Return all copies to: Environme al Health Permit/Services-1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATA PERM]T N0. INFO ' &'A EH 13-24 REV. IO/82 � �f 10/82 500 14-26 lY�,