83-199 - Laserfiche WebLink

Home Browse Search

e APPLICATION FOR PERMIT ` SAN JOAQUiN LOCAL HEALTH DiSTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. v .3— Telephone (209) 466-6781 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 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 Regulations ``\\of,'the San Joaquin Local Health District. Job Address ��C [� L � �� Subdivision Name Owner's Name-J7 r' LM �— Et- Address Phone ILI - J— Contractor's Name L__1`.E L� P�t�L.� License No Phone W TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR D OTHER U } DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE S FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial (l Open Bottom [] Manteca Dia. of Well Excavation LJ Domestic/Private F-�Gravel Pack Tracy Dia. of Well Casing Public [j Other Delta Type of Casing Lj Irrigation Approx. E] Eastern Specifications FICathodic Protection Depth Depth of Grout Seal 17 Geophysical 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') — UQ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION IX REPAIR/ADDITION JJ (No septic tank or seepage piavairmittedlable ifpublic thin 200fsewer is I n Installation will serve: esidence L Commercial Other Number of living units: Number of bedrooms _ Lot size2 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK F-1 Type/Mfg C--r- f-1 Capacity 1 a to c No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINENo. & Length of lines Total length/size LjN FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS Distance to nearest: Well Foundation 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 to become subject to workman compensation laws permit is issued, I shall not employ any person in such manner as iof California." the work for which Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of h .s permit is issued, I shall ploy persons subject to workman's compensation laws of California." The app 1 ust quiz i ions. Comp o drawing on reverse ide. Sign I: Ti tl e`s._.iL, � Date: J R �MENT NLY �'. E] Stk 466-6781 Application Accept byirkf Area Cam < � Lodi 369-3621 Additional Commen : Pit or Grout Inspection by Date Manteca 823-7104 Date ,��,� Tracy 835-6385 Final Inspection by �1'l. -�-+=— Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED �RJECEIVED BY DATE Q /9 IN CJ —1 10/82 500 EH 13-24 REV. 10/82C �j� ,�{ 14-26 �(/� �'