83-770 - Laserfiche WebLink

Home Browse Search

- � APPLICATION FOR PERMIT no List SAN JCAQUIN LOCAL HEALTH DISTRI � I � 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209')'466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEiSANI JOA QUIN LOCA12ATE ISSUED � (Complete in Triplicate) HEALTH USTRICT 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 Regulations of the San Joaquin Local health District. Job Address ' ner Subdivision Name Owner's Name n Address Phone 3$'' Contractor's Name (j J3 C kh p . License No. Phone ?e/7— 2 93 TYPCOF WELL/PUMP WORK NE47rWELL= t_ _ WELL`REPLRGEMENT� Wi Q-- DESTRUCTION=�=�= ;=- R PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS __JIndustrial ❑ Open Bottom Manteca ❑ Dia. of Well Excavation d , 1J Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public 'Other 0 Delta d Lj Irrigation A` j pEastern Cathodic Protection Deepthth Specifications Type of Casing Geophysical Depth of Grout Seal { ❑Other Type of Grout Surface Seal Installed by Repair Work Dane E:1 Type of Pump H.P. State Work Done Well Destruction Well Diameter p 1 ❑ Sealing Material (tap 50 ) N � Depth Filler Material (Below 50') 4 T-YPE�OF^'SEPTIC1'WORK:*pNFy14'INSTAI=L'ATI'ON_EC""REPAIR%AUDITION T�'T(No septic tater-k o`""r"seepage—'-'pi`t permitted"'i p bl`ic�sewer is�'""""'�"'� Installation will serve: Residence X Commercial _ Other available within 200 feet.) r Number of living units: Number of bedrooms � Lot size Q Character of soil to a depth of 3 feet: ;7 Water table depth O SEPTIC TANK Type/Mfg ,. Capacity 1 a No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity v Method of Disposal SEWAGE SYSTEM Distance to nearest: Well dation -Propertyoun DESTRUCTION ❑ I Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS DepthNumber j "Size M SUMPS Distance to nearest; Weil �j dation Property Line Q co 7�" q DISPOSAL PONDS ^!. !fix -^ x ._ x i ®[ S V:»-► p' 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 hiring or sub-contractingysignature certifies'the following: "I'-certify that in the performance of the work for which this permit is is ed, 1 shall employ persons subject to workman's compensation laws of California." The applicant all f r all required inspections. Complete drawing on'reverse side. - Signed X . Title: _( .G�Tl.GCf_ �[yx _eDate: FOR DEPARTMENT USE ONLY Application Accepted by i Area - Stk 466-6781 I Additional Comments; ED t Lodi 369-3621 III s Pit or Grout inspection by l Date Manteca 823-7104 Final Inspection by Cry Date t-7p L :Tracy 835-6385 k Applicant - Return all copies to: Environmental ealth Permit/Services 1601 F. Hazelton�Ave.,'P:O. Box 2009, Stk., CA 95201 � l i FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY, DATE, PERMIT N0. f INFO S =`L a� ?33---77 ; EH 13-24 'RFV. 10/82 _ 10/82 500 14-26