83-1053 - Laserfiche WebLink

Home Browse Search

APPLICATION-FOR PERMIT t ug� SAN JOAQUIN LOCAL HEALTH -ST..RICT SEP 2223 l 1601 E. HAZEL10N.AVE., STOCKTON, CA PERMIT NO. 3^ /6-3 Telephond_( 09} 466_-6781 1 ..�UAQ IN M Y _ T DATE ISSUED pZ pp p•� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6iE�1na�L.TH MISTR�C (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 .S 1 d d? Subdivision Name Owner's Name '/ /,L, ,_� Address -663 e )'Yr - Phone Contractor's Name a4-VA License No. 7Phone TYPE OF WELL/PUMA WORK: NEW WELL 0 WELL REPLACEMENT- DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE O , t r FOUNDATION AGRICULTURE WELL OTHER wELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V - - -Industrial 0 Open--Bottom — "'QrManteca - - Dia: -of Well-Excavation- y JN Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing i 17 Public Other Delta Type of Casing Ljlrrigation Approx. QrEastern Specifications ❑ Cathodic Protection Depth ` Depth`of Grout Seal Geophysical k, Type of j rout U Other Surface%6al Installed by Repair Work Done Type of Pump H.P. 1 State work Done Well Destruction U Well Diameter Sealing Material (top 56') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is } V" 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 of 3 feet: Water table depth 5 SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line i SEEPAGE PITS Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line p� DISPOSAL PONDS ❑ - 1 I hereby certify that 1 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. y 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 Califorria." 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.--k :.The applicant must call for all required inspections. Complete drawing on reverse side. s Signed' Title: :< " Date: OR DEPARTMENT USE ONLY Area ❑ Stk 466-6781 € ` Application Accepted by QT Lodi 369-3621 Additional Comments: Pit or Grout Inspecti#t . Date Lj Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all topicvir nm ental Health Permit/Services 1 F.&,It,,, ve., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. { INFO B3- f os3 10/82 500 EH 13-24 REV. 10/82 14-26