84-196 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT C j� t 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (204) 466-6781 � �,�_ fi DATE ISSUED g 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 San Joaquin Local Health District. Job Address Se /4 � Subdivision Name Owner's Name _ANN I—IN A Address Phone Contractor's Name m 2 CARGJ1C_ License No. 2L.I ��l Phone _)23-455W . TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK i SEWER'LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI;CULTURE WELL OTHER WELL PITS/SUMPS a. .„.. INTENDED USE TYPF OF�WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial (t ❑ Open Bottom (]Manteca Dia. of Well Excavation a =� �' Oil.- Wel Casing ❑,Domestic/yPrivate ,� ❑ GraveliPack ❑ Tracy � ; 9 �❑ P�7bl.i!c � ❑ Other ❑ Del to �� Type�of�Casing ❑ilrrgation �, - Approx. ❑ Eastern Specifications ❑ Cathodic °Protection Depth Depth of Grout Seal 1;---1-t Geophysical } I� Type of Grout �I ❑Other Surface Seal Installed by VJ Repair”-Work-Done ❑ Type of Pump i H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth I Fil ler Material (Below 501) o TYPE OF SEP'fi-.WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is �-�. -- .---i A-w�_. �+ available with;200"feet.) IC Installation will serv"l. •Residence Commercial Other Number of 1 iving,units___ , _�_,,..Numbe� f. bedrooms _-z- Lot size ( w�{ r Wi( Character of soil-to,..a.-depth of 3 feet: J�R� ater table depth SEPTIC TANK ❑ Type/Mfg } Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/MfgCapacity Method of Disposal SEWAGE SYSTEM Distance to`nea-4st: Well' ' Foundation Property Line DESTRUCTION ❑ t 4 LEACA14G, LINE No. & Length;of lines Total length/size n -FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS7>1 [j DepLli Si we _ Number > r SUMPS ❑ Distance to near#st: Welli Foundation Property Line DISPOSAL PONDS ❑ ` € I hereby certify that I have prepared this japplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rulesoand 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 issuedI shall not employlany, person in such manner as to become subject to workman� compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is is-ueds I shall employ p rsons subject to workman's compensation laws of California." The applican " call for all requi inspections. _ Complete drawing on reverse side. "Signed X �sf'+? +` ^.� Title:, ��P� Date: 6 7 DEPRR7M6T USE ONLY ❑ Application Accepted by Area Stk 466-6781 � Additional, Comments: ❑ Lodi 369-3621jt Pit or Grout Inspecti by Date Manteca 823-7104` Final Inspection by ��* i h rA.k-� 'Date--? LI Tracy 835-6385 x j I I Applicant - Return all copies to: Environmental Health Permit/Services 1601 L. Hazelton Ave., P.O. Box 2009, Stk, z�A 95201 I FEE BASE AMOUNT DUEAMOUNT REMITTED RECEIVED BY DATE PERMIT 0• T� I NFO EH 13-24 REV. 10/82 10/$2 500 � E 14-26 )i --) f , 7