83-665 - Laserfiche WebLink

Home Browse Search

rte. r ` APPLICATION FOR PERMIT , t y f SAN JOAQUIN LOCAL.-HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON,' CA PERMIT NO, �,( Telephone (209) 466-6781 -/y-Jf l DATE ISSUED f PERMIT EXPIRES i YEAR FROM GATE 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 4 and the Rules an Regulations of-the Sa Joaquin Lpcal Health District, Job Ad r ZJ�V Subdivision Name Owner's Name .Address - `,3/ 0 w,' Phone Contractor's Nam License No. Phone Q�j( /rJ rr ,,111 h Vv TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ® SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � { V ' � v INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation f. Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing q ❑ Public ❑ Other ❑ Delta FIrrigation Type of Casing _ , g prox. Eastern Specifications " F ❑ Cathodic ProtectionDepth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other , Surface Seal 'Installed by y" Repair Work Done ❑ Type of Pump r H.P. State Work Done - > - —�? - 7•.,4a� k ,Well Destruction FJ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') + aJ TYPE OF SEPTIC WORK: NEW INSTALLATION CJ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is 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 SYSTEM ' Distance to nearest: Well Foundation Property Line, DESTRUCTION ! LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ; SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county l 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, 1 shall not employ any person in such manner as to become subject to workmanls 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 applicant ust cal for all required inspections. Complete drawing on reverse side. Signed X� { ( �!7 Title: Date: P 610 / V OR DE RTMENT USE ONLY -¢ltvh r B 3— Appl,i(�cation Accepted by Area /� ❑ 5tk 466-6761 �� iI�6 3 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date / ❑ Manteca 823-7104 �. Final Inspection by �� . � Date /� ❑ Tracy 835-6385 Applicant - Return all copies to: . Environmental Health Permit/Services 601 F. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 I n BASE AMOUNT DUE "AMOUNT REMITTED RECEIVFD.BY DATE PERMIT N0 [e lis , EH 13-24 REV. 10/82 10/82 500 14-26 a . J