83-763 - Laserfiche WebLink

Home Browse Search

J APPLICATION FOR PERMIT - i - SAN JOAQLiN LOCAL HEALTH DISTRICT �� 1601 E. HAZELTON AVE., STOCKTON, CA PERPiIT`Pia. !J:�/ `b1' Telephone (209) 465-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete.in-Triplicate) Application is hereby made to the,Sar 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 Add ressSultidici5�4L[lame �,��(� 059 el40t1> 1q Owner's Name ;!?� 6 -e:3"Lt,&1' Address a Phone Contractor's Name _-46wgejI �4�� -License No. c26 Phone i �rit TYPE OF WELL/PUMP WORK: NEW WELL �' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO SYSTLM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKEWER LINES DISPOSAL FLD. S4 PROP. LINE j k FOUNDATION ',j \._ _ 0�s AGRICULTURE WELL OTHER WELL PITS/SUMPS _/5-49f { INTENDED USE TY,-EPDF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ' I dustrial U Open'Bottom ❑ Manteca Dia, of Well Excavation } Domestic/Private ,Gravel Pack ❑ Tracy Dia. of Well Casing °f 4 F 1-1Public ❑Other [] pelta -Type of Casing Irrigation Depthx. ❑'Eastern Specifications 115 F-1 Cathodic Protection p , Depth of Grout'Seal—4 f ❑Geophysical U Other Type of Grout I ' Surface Seal Installed by 4t a Repair Work Done ❑ Type of Pump. Te`�j H.P. State Work Done a I # Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth w' Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION No septic tank or seepage pit permitted if public sewer is b j , available within 200 feet.) Installation will serve: Residence Commercial _ Other` n 4 Number of living units: (Number of bedrooms LoCs'size ' Character of soil to a depth off,8 feet: , "Water table depth xSEPTIC TANK ❑ Type/Mfg1 Capacity lNo. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg{{ Capacity L Method of Disposal }SEWAGE SYSTEM Distance?to nearest: Well Foundation Property Line DESTRUCTION ❑ i - rx;';1.,- ., 1 LEACHING LINE LJ No. & Length of lines +" Total-length/size F - FILTER BED ❑ Distance to nearest: ylell ~~'Foundation �� Property Line a SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance'.to nearest: Well k Foundation Property Line DISPOSAL' PONDS.. 8 ❑h.. h.. . w+ .. - .r. ,.o ,«. . t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county i 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 workman6 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 must 1 fop.ac.tions. Complete drawing n reverse side. Signed X ' Title: Date: 2- �VARTMENT USE NLY a i Application epted .y Area ❑ Stk 466-6781 Additional Comments: . Lodi 369-3621 Pit or Grout Inspection by „r Date j U Manteca 823-7104 Final Inspection by _ Date i ' ❑-Tracy 835-6385 Applicant - Return all copies .to:F Environmenta, Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE BASE AMOU T DUE AMOUNT REMITTED RECEIVED'BY DATE PERMIT NO-- �• i INFO EH 13-24 REV. 10182 1} d 10/82 Soo 14-26 '