83-1351 - Laserfiche WebLink

Metadata

Thumbnails

Annotations

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT ,p 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. O,j # Telephone (209)466-6781 DATE ISSUED I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) ' 140e '� _� a: 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 Regulation of,the San ,loaquin Local Health District. 1L�TC3/V Subdivision Name Job Address & Owner's Name Address - Phone C3 Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION "`1 PUMP INSTALLATION SYSTEM REPAIR OTHER W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1Industrial U Open Bottom Manteca Dia. of Well Excavation a U Domestic/Private Gravel PackTracy Dia. of Well Casing Public Other Delta' t Type of Casing LjIrrigation Approx. Eastern Specifications Cathodic Protectionpth I De & � Depth of Grout Seal i Geophysical IType of Grout q 'l Lj Other Surface Seal Installed by cvv� Repair Work Done [f Type of Pump Hip. i State Work Done t1" Well Destruction El Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer i s available within 200 feet.)' installation will serve: Residence Commercial' s Other / �" s -'� . v :.'.~s fir•� '� Number of living units: T Number of bedrooms _ Lot size Character of soil to°a depth of 3 feet: k, } Water'table`depth SEPTIC TANK Type/Mfg i Capacity No. Compartments t PKG. TREATMENT PLT. Type/Mfg, Capacity. Method.,of Disposal SEWAGE SYSTEM Distance to nearest: Wel l Foundation"• Property Line j DUCTION - LEACHING LINE U No. Length of lines Total length/size ' s Property Line FILTER BED Distance to nearest: Well Foundation , SEEPAGE PITS [j Depths h Size Number . SUMPS U Distance to nearest: Well Foundation ' + Property Line sr DISPOSAL PONDS ❑ F E f I hereby certify that'I Have prepared this application and that n the work will- be done in accordance with"'S'aJoaquin county ordinances, state laws, and"rulesand regulations of the San Joaquin Local Health District. " Nome owner or licensed agent's signature certifies the following: "I certify that in the,perforrriance of the work for which this Pe rmit is issu I shall-not employ any p rson in such manner as to become subject to-workman compensation law 'of Cal'ifornia." Contractor's it n ar sub-contracting si ature certifies the following: "I certify that in tlierperformance`of the work for which this permit s s ed, I -Mall employ pe ons subject to workman's compensation laws of California � a The applica m call fo . 11 re .i.r d_i.nsp .t.ions-�Complet -on.r.everse side. , ,,,....,,,,, •._ �- 3 Signed Title: Date: 1 F pE?AXMENT JSF ONLY_ ; �s ^ Application Accepted by Are . �w t L ' ❑-Lodi 369-3fi2 Additional Comments: i * -^ ^^^ —E:]'Manteca-823-7104_,.. Pit or Grout Inspection r" * "" -- Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies ta: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE ' AMOUNT ,DUE AMOUNT REMITTED RECEIVED BY DATE ��PFIIO. INFO = � '�1''�d" f EH 13-24 REV./1'87J/�,82 io/sz soo , s 14-26 i . i r +