83-524 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL ,HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L 14 M �' (Complete in Triplicate) Application its 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�3(o N, kh . bl�l�lVJ4'1_1 T tj Subdivision Name Owner's Name Liw Ac=c_ /kms Address [ ' /VyDe. WRAF Phone Y/f32rc"SF�g Contractor's Name 'Al�l��s�-} � _S License No. PhoneR�(d—�} qa ,n TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR I] OTHEREJ - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^' i� Industrial U Open Bottom [] Manteca Dia, of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing 0 Public F-1 Other Delta Type of Casing 71 Irrigation Approx. 7] Eastern ❑Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal Type of Grout U Other Surface Seal Installed by Repair Work Done Fi— Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other )RLIp. Pf,er1� {N Number of living units: Number of bedrooms 'Z, Lot size 7y Character of soil to a depth of 3 feet: TdJ3 _ Water table depth SEPTIC TANK Type/Mfg C'D�(je. -- ��„E'.e1S� Capacity /(p®Q_ No. Compartments Z. PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Q e Property Line $d DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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 hi 'ng or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is sued, I shall employ pe V, ns subject to workman's compensation laws of California." The appli n tail for 11 requir inspections. Complet on reverse side. Signed X Title: Date: i FO DEPARTMENT USE ONLY Application Accepted by Area �tk 466-6781 Additional Comments: Lodi 369-3623 Pit or Grout Inspection y Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copie o: Environmental 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 14 'g3 3 S EH 13-24 REV. 10/82 10/82 500 14-26