83-544 - Laserfiche WebLink

Home Browse Search

v S � APPLICATION FOR PERMIT- SAN JOAQUIN LOCAL HEALTH DISTRICT ` Cl '!.l QO0 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. '33-54 l9 + .1Telephone (209) 466-6781 `� ! DATE ISSUED HEA.LTt • It-� SAN , UIN LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��'N S �'DISTRICT (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 compliarce 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 1/0-24,Q I/Ak) Quxy Subdivision Name Owner's Name Addresses __ Phone Contractor's Name , / �A. ji�l �5�,A) License Na. 7 Phone Q30-i—R?,C1'' TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C] PUMP.INSTALLATION ❑ SYSTEM REPAIR JI OTHER U 1 DISTANCE TO NEAREST: SEPTICIT.ANK SEWER LINES DISPOSAL FLD. PROP. LINE (/1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private FJ Gravel Pack EJ Tracy Dia. of Well Casing I �❑ Public ~w �-Oche? ' ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal f ❑Geophysical Type of Grout U Other Surface Seal Installed by i !� Repair Work Done Type of.Pump $exp H.P. State Work Done '( l iG� (. jk�-7 a 1 "-kms ri Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') l r` TYPE,OF.SEPT ff%WORK:•'"NEW INSTALLATION ❑,, REPAIR/ADDITI'ON J (No septic tank or,seepage pit permitted if public sewer is .� �' " "' , w,. • . available-within 200 feet.) p� Installation will �serve: ,Res,idence — Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water.tabl�e depth V SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of`D'isposal SEWAGE SYSTEM �, Distance.,.Lo.nearest: ....lfell,, _.-._. -"Foundation Property Line DESTRUCTION _ _ LEACHING LINE U No.,& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property LineCi SEEPAGE PITS ❑ Depth Size Number SUMPS LS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI I hereby certify that 1 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 hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." The applicant ust ca it for 4 r. " ir.ed inspections. Complete drawing on reverse side. �- signed X Lbl,61 Title: MENT U ONLY Application Accepted by Area _ d b ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date �v ❑ Manteca 823-7104 Final Inspection by Date g^lZ51!�a ❑ Tracy 835-6385 j Applicant - Return all copies to: Environme al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952 D1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO _ 45 EH 13-24 REV. 10/82 �L� 10/82 500 14-26