SU0006147 - Laserfiche WebLink

Home Browse Search

1w APPLICATION FOR PERMIT 'we SAN JOAQUIN LOCAL HEALTH DISTRICT Li 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 7 Telephone (209) 466-6781p DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the Saln Joaquin/L Cal Hea�/t)p District. / Job Address ��'� /�{��/"i 1�K.'1� _f��/4LSubdivisian Name �Q(!/� Owner's Name �'f?'J ,tyyll Address Phone Contractor's Name f p ense No. "7`0/3 Phone f TYPE OF WELL/PUMP WORK: NEW WELL L=JyWELL REPLACEMENT ❑ DESTRUCTION ❑ CA PUMP INSTALLATION Q� SYSTEM REPAIR ❑ OTHER ❑ (' DISTANCE TO NEAREST: SEPTIC TANK J/pq��Ie SEWER LINES _f� DISPOSAL FCD. PROP. LINE L r FOUNDATION -J=>t-m�-�AGRICULTURE WELL OTHER WELL PITS/SUMPS 1SO T G^ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V1 ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation [P,11�mestic/Private ravel Pack ❑Tracy Dia. of Well Casing _a ❑Public ❑Other ❑Delta ❑ T of Casing� / �� U Irrigation prox. ❑Eastern Specification Cathodic Protection Deep G Depth of Grout Seal S_61 4- ❑ Other Geophysical Type of Gro Surface Seauttinstalledby A ❑ /nom ;1`i F i Repair Work Done ❑ Type of PumpC H.P. 1`r State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is O 1 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 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. E Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS F-1Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 workmank 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 shall employ persons subject to workman's compensation laws of California." The appX/- .call for all required inspections. Complete drawingside� Signed % Title: L/f/�/� Date��__ D ARTMENT USEY 1 3 L Application Accept by Area �❑ Stk 466-6781 Additional Comnen s: - i'ge Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Insp�on by Date 6 /�� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Aealth Permit/Services 1601 E. Hazelton AvId7, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26