83-404 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT ~ r 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. T-3— L1 0 q Telephone (209) 465-6781 T DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) I 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 Regulation of the San Joaquin Local Health District. / t Jab Address lQ/S LCIp��GJ�� VCe Subdivision Name j% If C Owner's Name Address 33 2 �tt�/ ,a _A Ve-AM, hal-(pl�ne Contractor's Name }- Co. License No. 76 2-2, Phoneo`7DQ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATIONJ� SYSTEM REPAIR OTHER U } DISTANCE TO NEAREST: SEPTIC TANK _ `TSRF�• SEWER LINES DISPOSAL FED. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE tTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial 0 Open Bottom ;X Manteca Dia. of Well Excavation 1+I Domestic/Private X Gravel Pack ❑ Tracy Dia. of Well Casing �7 Public Other Delta Type of Casing jJ Irrigation lob/- Approx. Eastern Specifications c:, G} $ O ❑Cathodic Protection Depth t ` Depth of Grout Seal Q Geophysical jJ Type of Grout Other Surface Seal Installed by �- 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 ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is a.vailable 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: a Water table depth ` SEPTIC TANK Ej Type/Mfg Capacity No, Compartments i PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM �1 Distance to nearest: WeII Foundation Property Line DESTRUCTION L l LEACHING LINE J No. & Length of lines Total length/size i FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS ( I 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 workmanIs 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 f' this permit is issued, I shall employ persons subject to workman's compensation laws of California." k` The applicant st c 11 fora 1 re uired inspections. Complete drawing n reverse side. ' Signed K �� y � ,.Title:- - ci`ri~IPJ� Date: S/ - 'j Application Accepted by FOR DEPARTMENT USE ONLY 9Area ElStk 466-6761 Additional Comments: Q Lodi 369-3621 4 Pit or Grout Inspection by Date ��Z L-] Manteca 823-7104 Final Inspection by Date f 7 .d] Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Kfe., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO `3-140q EH 13-24 REV. 10/82 10/82 500 14-26