84-62 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, Telephone (209) 466-6781 -} DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appiication tis 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 Re ulla-tions of he n Joa uin Local H al h District. Job Address S Z t17t,Q Subdivision Name Owner's Namg (cilra.�--dam Address � Q Phone Contractor's Nam r License No. -2 Phone ,�� `S_/K, _ ; TYPE OF WELL/PUMP WORK: NEW WELL F-1 WELL REPLACEMENT DESTRUCTION ! t 171 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U -i'_J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom 7 Manteca Dia. of Well Excavation Domestic/Private Gravel Pack [�] Tracy Dia. of Well Casing I] Public Other Delta Type of Casing ❑ Irrigation Approx. [] Eastern Specifications I Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump, H.P. State Work Done n Well Destruction F-1 Well Diameter v :Sealing Material (top 50') _ �J Depth Filler Material (Selow. 50') TYPE OF SEPTIC WORK: NEW INSTRLLATION Lir REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) i 1� Installation will serve: esidence _ Commercial _ Other d NumbeF oof l' vingTunitsd Number of d ooms Lot size t /� , Character of soil to a depth of 13 feet ' Water table depth 3� -f-- SEPTIC TANK Type/Mfg nn �j�//�,,r��y Capacity (� No. Compartments __ lam' /, 1-2 PKG. TREATMENT PLT. ❑ #`i`Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance-to-nearest<'--Well.Tsj� ..Foundation. /Q _Property Line" S __ DESTRUCTION ~^� LEACHING LINE _1 No. & Length of lines �.- y�) Total length/size X FILTER BED _ Distance to nearest: Well d 1 ► Foundation /L7! Property.Line —:5--4- SEEPAGE PITS"• Depth ,V K r Size ` Number L SUMPS f LI Distance to nearest: Well le.70 Foundation /Q Property Line $� --DISPOSAI=-PONDS' ID 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. , Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permif7.i's'issued, I shall not employ any person in such manner as to become subject to workmarls compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work f6r which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applica must cal fo all required inspections. Complete drawing verse side. L Signed_X.... Title: 1Z i Date: s FO DPARTMENT U E ONLY Rp i ation Accepted by Area Stk 466-6781 Lodi 369-3621 Additional Comments: Pit or Grout Inspection by Date Manteca 823-7104 {� * „ Final Inspection b Date Tracy 835-6385 ,o-r Applicant - Return all copies to: Environmental H lth Permit/Services 1601 E. Hazelton Ave, P.O. Box 2009, Stk.', -CA- 95201 FEE BASE �AMOUNT DUE AMOUNT REMITTED RECEIVED BY / DATE PERMIT NO. INFO W S f -,23 I i EH 13-24 REV. 10/82 10/82 500 14-26