83-1315 - Laserfiche WebLink

Home Browse Search

APPLICATION FO'.i.PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephare (209) 466-6781 ``g a DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 � � f (Complete in Triplicate) v1 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 madesin 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 404 S y FRPSN0, STO KTQN. Subdivision Name Owner's Name _ , Address 1 340 W. WASHINGTON STKN Phone 944-5800 Contractor's Name ENTERPRISES License No. 265964 Phone 466-071 r TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM'REPAIR ❑ OTHER U O 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 FI Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public 7A Other ❑ Delta Type of Casing �jIrrigation Approx. E] Eastern Specifications F-1Cathodic Protection Depth Depth of-Grout Seal ❑Geophysical Type of Grout' ' ❑Other Surface Seal Installed by Repair Work Done Type of Pump 14.P. State Work Done " Well Destruction F-1 Well Diameter Sealing Material (top 50') r Depth Filler Material (Below 50') k TYPE OF SEPTIC WORK: NEW INSTALLATION LJ septic tank or seepage pit permitted if public sewer is �� REPAIR/ADDITION available within 200 feet.) 'Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property tine 4 rE7'RUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER RED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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 permit is issued, I shall not employ any person in such manner as to become subject to wcrkmar!; compensation laws of California." ollowing: "I certify that in the performance of the work for which Contractor's hiring or sub-contracting signature certifies the f this permit is issued, I shall employ persons subject to workman's compensation laws of California." i.-The applicant m all for all required inspections. Complete drawing on reverse side. Signed X Title Date: FORD A E E ONLY Area tk 466-6781 Application Accepted by Additional Comments: 1�*_ odi 369-3621 Pit or Grout Inspection by DateE Manteca 823-7104 Final Inspection by Date/l/J[S/a'3 ❑ Tracy 835-6385 Applicant - Return all copies to, . E ironmental Health Permit/Services 160�'E�.' Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 044 I OGa `(3 (5 [ (" d 1 10/82 500 EH 13-24 REV. 10/82 r ( %A_" � 1 14-26 +�