89-937 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DIS f Q�jEaluz 1601 E. HAZEL T ON AVE., STOCKTOIC+ APR.Telephone (209) 466-6781 �,' PERMIT EXPIRES 1 YEAR FROM DATE I �E�� A ,,7 X989 (Complete in Triplicate) p NM�t' H � cNTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct a��1,'��!�Rt I I� kfiEffi ICli�is application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welnum�e Rules and Regulations of the San Joaquin Local Health District. / nn Job Address ►" Cityi_S a/011 Lot Size �` PM Owner's Name Address 370> Sa�,��i.�.�� S73L Phone�4`y�94 Contractor Address Q License Ivo�Sla$ - Phone 57.7 !W-- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 11 SYSTEM REPAIR El OTHER 1-1 / DISTANCE TO NEAREST: SEPTIC TANK ,trt0 r SEWER LINES IR2 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation __.Approx. Depth```..``l I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump � H.P. , L State Work Done _ Well Destruction ❑ Well Diameter �! Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) y n Installation will serve: Residence_ Commercial_ Other y r 1 Number of living units: Number of bedrooms S } Character of soil to a depth of 3 feet: Water t SEPTIC TANK ❑ Type/Mfg Capacity No. Cori PKG. TREATMENT PLT. ❑ Method of Ck I� Distance to nearest: Well Foundation Property Line H LEACHING LINE ❑ No. & Length of lines Total length/size LHEAtL H FILTER BED ❑ Distance to nearest: Well Foundation Property Line RMITf SERVIC t� SEEPAGE PITS I I Depth Size Number SUMPS P Distance to nearest: #Well Foundation Property Line —� r DISPOSAL PONDS ❑ 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 Diltrict. 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's 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 compensa- tion laws of California." The applic nt mu t call for all required inspectio . Complete drawing on reverse side. Signed X Q^`-z—� Title: _ � Date: FORPARTMENT USE ONLY Application Accepted by Date s 7—' _A" Area Pit or Grout inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 /000 FEE AMOUNT DUE AMOUNT REMITTED RECEIVEp$Y DATE PERMIT NO. INFO ♦ EH 13-241REV.ri�5i 36 `SI- 10 EH t4-26 0 a y