SU0004989 SSNL - Laserfiche WebLink

Home Browse Search

` lF, APPLICATION FOR PERMIT �I �/ ��% ' ✓��v `_`� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. (� Telephone (209) 466-6781 v DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) n Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein 00 described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump j and the Rules and Regulations of the San Joaquin Loc 1 H alth District. Job Address �I' p�/ AC 0O�e- t JA X.-CSubd�i1vision Name 1 3� `{ rl�E ` Owner's Name �,��2 ��GS Address 8q81�� .�bG S^yt I.c� �' G� Phone 1 - Contractor's Name �jy� �y{�ticense No. Phone Pogo � TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U bw PUMP INSTALLATION SYSTEM REPAIR (_j OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ~ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing h" 0 Public F-1 Other Delta Type of Casing V Irrigation Approx. Eastern Depth Specifications F-1D Cathodic Protection _ - Depth of Grout Seal ` 1-1 Geophysical Type of Grout [ Other Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done t. Well Destruction U 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 is rs !k available within 200 feet.) Installation will serve: Residence _ Commercials Other Number of living units: Number of bedooms Lot size L Character of soil to a depth of 3 feet: G�a Y ��- �a m Water table depth SEPTIC TANK L)if Type/Mfg {�c�TTtS� ��{ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well _ Foundation Property Line I DESTRUCTION / LEACHING LINE No. & Length of lines .�- /,ZS fO 4%�( Total length/size f2� l FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth 2S Size Number 2 SUMPS Distance to nearest: Well Foundation Property Line } DISPOSAL PONDS Cl 7 i Cvr 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 s 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 ilm this permit is issued, I shall employ persons subject to workman's compensation laws of California." f, The applicant mu t call required inspections. Complete drawing on revel�iei Signed X Title: K Q Date: /O f O J BOR XPART NT USE ONLY Application Accepted by ; % � Area zZ [ " Stk ,466-6781 Additional Comments: / !; ,%c+:Ys Ld J i�/S 1�F' -�10�%¢' G!C°C°z'Yl it'ez Lodi X369-36-2 Pit or GroutInspection by � y J` `r 5-31'f- " el— �'-�- , U Manteca 823-7104 �. Final Inspection by r` Date _ -, Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I I INFO EH 13-24 REV. 1D/82 LO/82 500