83-561 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR,PERI-IT SAN JOAQL!N LCEAL HEALTH DISTRICT € 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. - (o Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete.ir Triplicate) Application is hereby made to theiSan "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 tie San Joaquin Local Health District. p Job Address Ms� S WA&A EA .4146 Subdivision Name Owner's Name Q26 e'&4d Address S,¢ E Phone ,QZa'c� Contractor's Name License No. Llys 17( Phone 4&s'-_39-7 / TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT Q DESTRUCTION U ,--.PUMP`,[NSTAL'LATION SYSTEM REPAIR OTHER"�I� a_ DISTANCE TO NEAREST: SEPTIC TANK ;' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE tSF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I JIndustrial U Open Bottom Manteca Dia, of Well Excavation Domestic/Private Lj � Gravel Pack Tracy Dia. of Well Casing Pui3licE]Other Delta ` IIrri"ation { Type of Casing Lj g Approx. Eastern Specifications Cathodic Protection depth Depth of Grout Seal 17 Geophysical t� U Other Type of Grout Surface Seal install ed�by Repair Work Done ❑ Type of Pump, H.P. State Work Done Well Destruction LJ Well Diameter Sealing Material (top 50') t _ Depth Filler Material (Below 50') '. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Z (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) Installation will serve: Residence _w1l Commercial Other Number of living units: Number of bedrooms _ Lot size /� G]Q ' Character of soil to a depth of.3 feet: L Water table depth SEPTIC TANK Type/Mfg — ' Ca acity Tgo p_ No.,Compartments � PKG. TREATMENT PLT-[J- Type/Mfg. opacity Method of Disposal SEWAGE SYSTEM Distanceto nearest: Well Foundation -/0 Property Line O DESTRUCTION ❑ i Sia LEACHING LINE No. & Lrength of lines / 4fZ7 Total length/size; 2- FILTER FILTER BED Distanc-e to nearest: Well Foundation /2 Property Line SEEPAGE PITS ,"Dep'th "�/Z�r" Size �,3 i� Number SUMPS U Distancei to nearest: WelSI Foundation Property Line (OV f DISPOSAL PONDS ;ys I hereby certify that I have prepared this-.application and that the w e in accordance wi an oaq n county i ordinances, state laws, and rules land regulationsiof 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 iis 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, I shal1 employ persons subject to.workman's compensation laws of California." The applicant must call for all required inspect' ns. Complete draw, on reverse side. Signed X $ Title: Date: FOR DEPARTMENT USE ONLY f Application Accepted by J Area [� Stk 466-6781 „ AdditionalComments: Lodi 369-3621 k Pit or Grout Inspection bye Date" "'"' ❑ Manteca 823-7104 Final inspection by ,'I Date Tracy 835-6385 Applicant - Return all copies to-. Environmental Health Permit/Services 1601 E. Hazeltor Ave., P.D. Box 2009, Stk., CA 95201 I` FEE BASE AMOUNT -DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. � INFO L EH 13-24 REV. 10/82 v10/82 54'O 14-26