83-111 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQU `I LOCA! HEALTH DiSTRICT 7 J 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-5781 r ,�[ ERMI1T EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED JJ (Complete in Tri licat /G76 04o-0 Application is ereby made to the San Joaquin Loca 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 Reculatinns4of the San Jo_agu-in_,Local HPalth.District. , Job Address �J j13� �., _ ♦! ..moi{Jt °J vision Name -��,.,.-rte �.I� � . �°�✓� �.�.,. Owner's Name t Address AR7/ Al. GF�isto%31 �b/,__ Phone �`�1(-3 7,1 Contractor's Name� °rFsJ IS License No. _ _ - Phone( �2 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation _ i Domestic/Private U []Gravel Pack Tracy Dia. of Well Casing ❑ Public ❑ 0ther ❑ Delta T [� ype of Casing F', irrigation Approx. ❑ Eastern Specifications } ❑ Cathodic Protection Depth V Geophysical Depth of Grout Seal -: ❑ U Other Type of Grout Surface Seal Installed by e Repair Work Done -Type of Pump H.P, State Work Done .Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF`SE-PTIC WORK: NEW 1NSTALLATIONIV REPAIR/ADDITION LJ (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 Character of soil to a depth ofWater table depth SEPTIC TANK, Type/Mfg3 feet: No. Compartments �- PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal ` SEWAGE SYSTEM Distance to nearest: Well 'Foundation Property Line C f DESTRUCTION ❑ LEACHING LINE No. & Length of lines Total length/size _ �, !1 -7 FILTER BED ❑ Distance to nearest: Well Foundation Property Line h SEEPAGE PITS ❑ Depth size Number + SUMPS U Distance to nearest: Well Foundation Property Line h G DISPOSAL PONDS T 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 become subject to workmank 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 i issued, I shall employ persons ubject to workman's compensation laws of California." The applica t call f all re r d ctionF. Complet drawing on reverse side. Signed itle: vl-� _ Date:'J.— FOR DEPAR T � I ... Application Accep Additional Comore ted b Area /�— ❑ Stk 466,5781 s: + Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return.all copies t nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �� I 3 EH 13-24 REV. 10/82 10/82 500 14-26