83-288 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT } SAN JOAQUiN LOCAL HEALTH DISTRICT F L'9$�E 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ` Telephone (209) 466-6781 GATE ISSUED U"`2_2`g3 PERMIT EXPIRES I 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 v described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. IS62 for well/pump and the Rules and Regulations of t e San Joaquin Local Health District. �l Job Address d 1 � rc c 14 ��_ Subdivision Name I J4 Owner's Name ii p Address A, c r.¢ [ Phone Contractor's Name License No, Phone Y i TYPE OF WELL/PUMP WORK: NEW WELL FV WELL REPLACEMENT ❑ DESTRUCTION ❑ G� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK `S - SEWER LINES t DISPOSAL FLD.��_ PROP. LINE /O I} FOUNDATION U AGRICULTURE WELL [a t{ OTHER WELL !J� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom /Eastern ca Dia. of Well Excavation N Domestic/Private Gravel Pack Dia. of Well Casing ❑ Public Ljjother Type of Casing Irrigation {Approx. Specifications ❑Cathodic Protection Depth Depth of Grout Seal { ❑Geophysical Type of Grout Lit J44 Je ki t7 ❑Other Surface Seal Installed by IL owAl'er Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well .Diameter Sealing Material (top 50') — Depth 4" Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is O , 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 t 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 L SEEPAGE PITS [� Depth Size Number Y Y SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county 4 ` ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. k 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 compensation laws of California." Contractor's hiring or sub-contracting signature ce s the following: "I certify that in the performance of the work for which this permit is issued, I shall employ rsons ect to workman's compensation laws of California." The applicant ust call or requ' nspections. Complete drawing on reverse side. f Signed,X Title: Date: f R �tTME P� SE ONLY ❑ Stk 466-6781 Application Accepted y ,. Area -�i Additional Comments ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date �<<—F�,J'S ❑ Tracy 835-6385 III 1' ' .Applicant - Return all copies to: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 9 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVER 8Y DATE PERMIT N0. INFO �-f Z�-83 10/82 500 EH 13-24 REV. 10/82 14-26