83-760 - Laserfiche WebLink

Home Browse Search

M APPLICATION FOR PER+'f!T SAN JOAQU;" LOCAL HEALTH DISTRICT 7601601 E. HAZELTON AVE., STOCKTOM, CA PERMIT NO. Telephone (209) 465-6181 DATE ISSUED 7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in; Triplicate)' Application is hereby made to the San Joaquin Local Health'District fora 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 Sdnjoauirl Local HNalth Dista t, Job Addres e Owner's Nam 4 Address f'C) - -,PhondV10 e . License No. Phone Contractor's Na r6' TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR - ❑ OTHER F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSs1 INTENDED USE TYPE OF WELL PROBLFM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing Public Other Delta F� ❑ . ❑ ❑ Type of Casing 'Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth ❑' Depth of Grout Seal r. ❑Geophysical Type of Grout (❑Other ' Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane \ Well Destruction ❑ Well. Diameter Sealing Material (top 50')Filler Material Material (Below 501) I Depth TYPE OF SEPTIC WORK: N& INSTALLATION E REPAIR/ADDITION j] (No septic tank or seepage pit permitted if public sewer is ✓J Commercial c Other available within 200 feet.) Installation will serve: Residence — j Number of living units: Number of bedrooms Lot size E _-�_ i Character of soil to a depth of 3 feet:# Water table depth SEPTIC TANK' Ek- Type/Mfg s:+ Capacity Q(�_ No. Compartments r i PKG}. TREATMENT PLT: ❑ Type/Mfg k""" >" V-Gapacity. Method of Disposal SEWAGE'SYSTEM J� " Distance to nearest: Well ^<rFoundation //S Property Line DESTRUCTION IT LEACHING LINE ` 0jNos+&;.Length of lines' ® -Total l�ngth/size. ® y� FI ETER,BED ; ❑ Distance-to nearest: Well J--L3_ Foundation Property Line _ SEEPAGE PITS Depth i Size`.- _Nu mb --�,.�,� er SUMPS �I Distance to nearest: i Well Faundation Property Line � 'ti DISPOSAL PONDS ❑ d � I hereby certify that I have prepared thisapplication a d 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,rshall not employ,any` person, in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-contracting`s.ipature certifies',the following: "I certify that in the performance of the work for which this permit is issued, Iishall employipersbns subject to workman's compensation laws of California." The ap`plica must call f. all equired inspections. Complete drawing on r erre side. Signed X _ Title: �r 'r Date 42 ^FOR ARTMENT USE ONE ZZA lArea i ion Accepted by _ r�_-___ ❑ Stk 4fi6-6781 fLodi pP P ffff ' d `Additional Comments: ❑ 369-3621 !, D Pit or Grout Inspection by ate Manteca 823-7104 ❑ Final Inspection by ��/ Date s ❑ Tracy 835-6385 Applicant -'Return all copies to Environmental/lealth Permit/Services 16 1 E. Haze ton Ave., P.O. Box 2009, Stk., CA 95201 i FEE BASE AMOUNT :DUE AMOUNT REMITTEE) RECEIVED BY DATE PERMIT N0, INFO # e F 10/82 500 EH 13-24 RFV, 10/82 14-26