83-641 - Laserfiche WebLink

Home Browse Search

a APPLICATION FOR PERMIT SAN J0AQj1N LOCAL HEALTH ,i5T41CT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. (►O�1 Telephone (209) 466-6781 DATE ISSUED .,I 0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin L'ocel Health District for a permit to construct and/or install the work herein in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump described. This application is made and the Rules and Regulations of thelSan Joaquin Local Health District, Job Address 32- Subdivision Name G ' Address -5�4 - Phone Owner's Name � Phone Contractor's Name License No. tYPE OF WELL/PUMP WORK: NEW WELL F7WELL REPLACEMENT [} DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ } ' SEWER LINES DISPOSAL FLD, PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS ; FOUNDATION AGRICULTURE WELL OTHER WELL CONSTRUCTION SPECIFICATIONS INTENDED USE *T.YPE OF WELL PROBLEM RREA,.N`" y t 17 Industrial � ❑ Open Bottomw ❑ Manteca � Dia. of Well Excavation +. wi ! ❑ Pack ❑ Tracy Dia. of Well Casing Domestic/Private Gravel. Public -❑ Other'"s ❑ Delta. tom, •)�L Type of Casing � Irrigation Approx. ❑ Eastern Specifications In DeF ' ❑Cathodic Protection ptDepth of Grout Seal ❑Geophysical F r WType of Grout ❑Other ' Surface Seal Installed by I R f Repair Work Done Type of Pump H p State Work Done �J Well Destruction ❑ Well Diamete l Sealing Material (top 50') F Depth 6f Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage piavallableewithinpublic feete) 35 Installation will serve: Residence. Commercial _ Other ——Z ��4 Itt Number of living units: __ lNumber of bedrooms _ __,__ Lot size h Water table deptr�a Character of soil to a depth of,$.feet; C.� II_ EPT1C TANK C�[G Capacity No. Compartments 54 Method of Disposal I�PKG. TREATMENT PLT. ❑ Type/Mfg: Capacity _ Property °SEWRGE SYSTEM Distance to nearest: Well =� Foundation Line` I DESTRUCTION 1 No. & Length of`lines .� `*'Vd / Total length/size+ O X LEACHING LINE 1 g t -� Property Line FILTER BED ❑ Distance to nearest: Well /t7 v foundation P -.---- Size 3 3 Number 3 SEEPAGE PITS �j Depth _2 .r Pro pert Line — SUMPS } ❑ Distance to nearest: Well/D D t Foundation y DISPOSAL PONDS # ❑ ��;� ��i ��$ '� �' _ I hereby certify that Ii have ru.}epaand-r`egulatptredl.icat cao h JoaqueinwLoca]ork ,Heall bthdDistt�ietone in cC, n . with San Joaquin county F ordinances, state:laws,a Home owner or licensed agent's s-i,gnature certifies'the-following: "I certify tha,ljtn'the performance of the work for which this permit is issued, I shall not employ any person such-manner as to became sub3ect to workmanR compensation laws of California." Contractor's hiring or sub-contracting signature cert.i.fier _ s��the following. ertify that in the performance of the work for which this permit is issued, I shall employ persons subject, Workman's compensation laws of CaliforaA �t The applicant must c 1 for a rlequi ins ctions.••--Compl.ete�drawing_o/n reverse e Date: 3 Signed X Title: T, I FO D ARTM T USE 0 1,�4k Area ` $ f-3❑ Stk 466-6781 i Application Accepted by r !� as ❑ Lodi 369-3621 k Additional Comments: fIIIDate _,£ )s ' E] Manteca 823-7104 i s Pit or Grout Inspection 4iy ❑ Tracy 835=6385 Final Inspection by �. Date + + # P.O. .Box 2009, Stk., CA 95201 Applicant - Return all Copies to�L Environmental. Health Permit/Services 1601 E; Hazelton Ave- � k FEE BRSE AMOUN7+ DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INF 10/82 500 EH 13-24 REV: 10/82 c� 14-26 -