83-1152 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 93.- Telephone 3.- Telephone (209) 466-6781 y} DATE ISSUED V PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sa'Joaquin Local Health District for a permit to construct and/or install the woYk 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 'Zy 3 Sy 5 -• �Y6 c�7'1 G/ Subdivision Name Owner's Name AL 13; S J7p JS _ Address �y.�-r�i� So, ��'�YfGI� IQ�� oy Phone Contractor's Name AlY1`l mlJ/y fso/Y License No. j; y$" Phone 57,73-V-11 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑^ OTHER❑ DISTANCE TO NEAREST: SEPTIC TANK a SEWER LINES *� i $DISPOSAL FED. = PROP. LINE �n" .. F.. . FOUNDATION -- t--.- •AGRI•CUITURE WELL- ---— _ OTHER WELL, - PITS(SUMPS �•� INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � IJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t i Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing g ❑ Public ❑Other. ❑ Delta Type of Casing ? Irrigation Approx. []'Eastern �"^'^ Specifications E]Cathodic Protection Depth Depth of Grout S1al-w___°^�--�� ❑ Geophysical Type of Grout Other Surface Seal In_stal.led.by 1 11 .r Repair Work Done ❑ Type of Pump H.P. �t,t , estate Work Done f �*t Well Destruction ❑ Well Diameter Sealing Material (top 50`) Depth Filler Material (Below 50'} } r .+.' 0- i V\ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if:public sewer is available within 2.0 feet.) - Installation will serve: Residence / Commercial _ Other " Number of living units: �_ ?Number of bedrooms . .,..,_Character:o.f soil-to-a_depth of 3 feet: S4IV41 Water table depth SEPTIC TANK VI Type/Mfg fre Ce9r77+ GAIv,-. Capacity /.5970 No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg 4 Capacity Method of Disposal SYSTEM ❑ Distance to nearest: Well %� Foundation% Property Line DESTRUCTION_ LEACHING LINE, ❑� No. & Length of line LEACHING length/size FILTER BED #', Distance td�neae&t:�- Weld 655- :1 Foundation 6s'" Property,Line SEEPAGE PITS, { ❑ Depth Size Number SUMPS LI 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. f' 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,tc beeome..subject to workmang compensation laws of California." I !° Contractor's hiring or sub-contracting signature certifiesYthe;fol]owing_ "I�certify that in the performance;of the work for which f5 this permit is issued, I shall employ persons subject to workman's compensation lawsof-Cal"ifo"rnia' k The applicant muSj call for all required inspections. Complete drawing on reverse side. _ t<; 4 Signed X c�t Title: nate' "J o�-1 6-' 83 FOR DEP RTMENT USE ONLY `^� Application Accepted by Areay ❑ 5tk 466-6781 Lodi 369-3621 Additional Comments: ❑ j - t Pit or Grout Inspection by Date- Final Inspection Ty Date 01 t A/ Tracy 835-6385 I` Applicant - Return all copies to: nvironmental Health Permit/Services 1601 E. Hazelton ti ce.,P .O. Box 2009, 5t k., CR 95201 i F�_�ASI AMOUNT DUE AMOUNT-REMITTED RECEIVED BY DATE ;PERMIT NO. a 50014-26 -- EH