85-1404 - Laserfiche WebLink

Home Browse Search

l�'v k-4-r— �vw APPLICATION FOR PERMIT �J_� �T•�?fN JOAQUiN LOCAL HEALTH DISTRICT pT F • _ 1601 E. HAZELTOTelephone AVE., 66-6781 CA PERMIT N0. /b(iv�-6 v V Telephone (209) 466-6781 w �� DATE ISSUED ��; , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /C" (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. //)► ©we Job Address 1 7 q S 4&&IA4 /'t e/ Subdivision Name 1 /T 6-' " Owner's Name Address 1-79-04 f if A447f y Phone _81P.,?_S4f r(,_ Contractor's Name l r �Y �.� License No. X( � Phone &M-7f2.Z. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR U OTHER U DISTANCE TO NEAREST: SEPTIC TANK VC-1 SEWER LINES DISPOSAL FLD. .PROP. LINE FOUNDATION C AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ff AV I Industrial (J-Open Bottom MantEea Dia.-of Well Excavation - omestic/Private gravel Pack ❑ Tracy Dia. of Well Casing Public Other ❑ Delta Type of Casing F, Irrigation Approx. Eastern Depth Specifications 0 � Cathodic Protection Q Depth of Grout Seal 17 Geophysical Type of Grout G L_J Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other C 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 �! PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED 17 Distance to nearest: Well Foundation Property Line SEEPAGE PITS F-1 Depth Size Number Y SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C� 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. 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 certifies the following: "I certify that in the performance of the work for which this permit is is�ued, I shall e loy persons subject to workman's compensation laws of California." The applic mus"t ca for 1 required inspections. Complete draA�,v rse side. Signed Title: Date: OR MENT USE ONL—T Application Accepted by / � � Area C � Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Qnrl�f'v^go Date 0 Manteca 823-7104 Final Inspection by i� ` Date ! 2 j S L Tracy 835-6385 Applicant - Return all copi to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I INFO 3.00 14H EH 13-24 REV. 10/82 10/82 500 14-26