84-693 - Laserfiche WebLink

Metadata

Thumbnails

Annotations

F F APPLICATION FOR PER`rI,T R. SAN JOAQLiN LOCAL HEALIH DISTRICT 1601 E. HAZELTON AVE., STOCKT0N, CA PERMIT NO. 3 Telephone (209) 466-6781 q DATE ISSUED PERMIT EXPIRES 1 YEAR FROM 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 I 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 ofithe San Joaoui.n Local Health District, 3 Job Address Subdivision Name Owner's Name �7'�Address 7 Phone. Contractor's Name c.,U License No. �3�7,�r Z Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK) SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy._9pia.�of�WelJ4Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation # Approx. Eastern # ` Depth ❑ .�.- Specifications — ❑ Cathodic Protection � --Depth of-Grout Seal• - , k ❑Geophysical P Type of Grout F-1Other Surface Seal Installed by Repair Work Done ❑ Type of Pump € H.P. Stat Wo'r one Well Destruction ❑ Well Diametler Sealing Material (top 501) _ Depth Filler Material (Below 50`) _ t r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ R . DIT I (No septic tank or seepage pit permitted if public sewer is ( & available within 200 feet.) Installation will senve: Residence Commercial Other Number of livings Number of bedrooms Lot s ze - Character of soil to a epth o'.f 3 feet: ,� Water table depth -Z : SEPTIC TANK LJ Type/Mfg F Capacity_ -_ No. 'Compartments PKG. TREATMENT PLT. ❑ Type/Mfg f Capacity "r Method of Disposal + SEWAGE SYSTEMDistance to nearest: Well Foundation fQ Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. &`Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 I SUMPS Dtancece to : Well DISPOSAL PONDS oundationy - F SEEPAGE PITS Depth! a ®Size ❑I { /�A�f'P /P �" Property Line E Li �` , I hereby certify that I have prepared this app lication and that�the work will be done'yiinn"accordance ewwith YSan Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Healfh' Diatrict. k Home owner or licensed agent'srsignature 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-workman t, compensation laws of California." 'Contractor's hiring or sub-contracting signature certifies the:fro-llowi.ng:.-"•I=-certify that in the performance of the work for which A `4".01 s permit is issued, I shall employ persons subject to workman's compensation laws of California." f The applicantm t call fo all squired inspections. Complete drawing on reverse side. Date: r7 Signed X_� �� _ Title: 17 F R DEPARTMENT USE NLY Application Accepted by_ Area } _ ❑ 5tk 466-6781 Additional Comments: 17 Lodi 369-3621 or Crout Inspection by Date Manteca 823-7104 Final Inspection by Date3� ❑ Tracy 835-6385 I Applicant_.- Return all copies to: Environment a Health Permit/Services 1601 E. )Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE. AMOUNT., DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ► S, ear s y—lry9� i 10/82 500 EH 13-24 REV. 10/82 F 14-26 4,