86-1504 - Laserfiche WebLink

Home Browse Search

s c e APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED i } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED { (Complete in'Triplicate) i 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 Regulations of.the San Joaquin Local Health District. Job Address jf0f/yWV �•/r'ZQ Subdivision Name. ,.—� -- — Owner's Name_...,`j/,t,�.. G/LLisyie _ _Address X^Iwe Phone Contractor's Name Aiai01sok" License No. Phone TYPE OF WELT./PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION ❑ PUMP INSTALLATION <❑ SYSTEM_REPAIR OTHER F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUREWELLOTHER WELL PITS/SUMPS t INTENDED USE TYPEIOF WELL f MPROBLEM'AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom [ Manteca ; Dia. of Well Excavation k U Domestic/Private Gravel Pack 'Q Tracy \a Dia. of Well Casing Public Other I [ .Del ta. � Type of Casing III ❑ Irrigation ' �Approx. ❑Eastern Depthro Specifications Cathodic Protection Depth of Grout Seal ❑Geophysical ) jjj '� i Type of Grout v � Y [Other r - Surface_Seal.Installed-by-.--- Repair Work Done FJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth; Filler Material (Below 50')3 ., y.a. i TYPE OF SEPTIC WORK: NEW INSTALLATION'JJ REPAIR/ADDITION E) (No septic tank or seepage pit permitted if public sewer is r 1 � available within 200 feet,) Installation will serve: Residence / Commercial _ Other l y ° F Number of living units: R Number of bedr.Iooms X Lot size e>wljr r Character of soil to a depth of. 3 feet: Water table depth SEPTIC TANK Type/Mfg jPore C&srr CvNa Capacity /,0067 No. Compartments ,'Z PKG. TREATMENT PLT. [] Type/Mfgcapacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line 1.0d f DESTRUCTION ❑ i ( + LEACHING LINE No. & Length of lines Total length/size r7 i FILTER BED _..•DYstancle to nearest: Well 1-4-0 , Foundation .To Property Line SEEPAGE PITS [] Depth 1 ' size f-Vilj -/`2r Number— 3 SUMPS-- 4.Ya>at-may ---Distance tornearest: Well :Z;t 6' Foundation /tV ' Property Line DISPOSAL PONDS ❑ ' 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 workman$ 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 subjecf"to workman's compensation laws of California." The-applicant m st call for all required inspections. 'Complete drawing on reverse side. Signed.X .�G6:/ � i iTitle: Date- RMA ate: T- �RA TMENT USE ONLY _ n r Application Accepted by I + Area —�l l l'L [} Stk 466-6781 Additional Comments: .z ❑ Lodi 369-3621 Pit or Grout Inspection by -W Date Manteca 823-7104 Final Inspection�byf 'NO _/A=&_" 's __ Date Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 161 E. Hazelton Ave., P.O. Box 2009, Stk.,.CA 95201 ( s FEE BASE AMOUNT DUE at F AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. - INFO © o 11 1 $y Sfo S�0_15 o L1 a EH d13-24EV. 10/82 lO/82 500 e 14-26-%