83-1090 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQLI's LOCAL HEALTH DISTRICT 15CI E. HAZELTON AVE., STOCKTON, CA PERMIT NO. r { V Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (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 ( C fir . 611- Owner's Name Address �_5 tG SL.LMvvuA r - Serr.IlC1L Phone _ tp 19- LJWrf-5110 Contractor's License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK )o SEWER LINES DISPOSAL FED. 2Gy PROP. LINE 50, FOUNDATION -2-0 AGRICULTURE WELL J Q� OTHER WELL �()�__ PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack__,D Tracy Dia. of Well Casing 2 Publ'c ❑Other Delta Type of Casing S+CY- Irri tion Approx. Eastern Specifications Cath dic Protection Depth ❑Geophlysical Depth of Grout Seal F-1Othe� 1r�� Type of Groot LI�V"`�✓5` ffL ! Surface Seal Installed by Repair Work Done ❑ Type of Pump'-500 H.P. �7 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (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 p1 Character of soil to a depth of 3 feet: Water table depth 0� SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG._TREATMENT PLT. ❑ Type/Mfg t Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C Distance to nearest: Well Foundation Property Line SEEPAGE PITS F—j Depth Size !• Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1:1 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 workmant 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 is issued, I shall employ persons subject to workman's compensation laws of California." The applicant m all for al re ired ins ections. Complete drawing on reverse side. Signed X k Q Title: Q l KC Date: R DEP MENT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by 1 Date Lj Tracy 835-6385 Applicant - Return all copi s to: En vi onmental Health Permit/Services 1601 E. Ha elton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO s _ n Io 43 3 - 1 � EH 13-24 REV. 10/82 �rj r 10/82 500 14-26