85-1193 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL:HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKT ON, CA Telephone (209) 466-6066 PERMIT EXPIRES 1 YEAR`FROM`'DATE I6SUED'`1 a"ct (Co 01 in Triplicate} 3 '.•� + .. t".�. '1.. , $;`ri#1:; !"y ;+r ;. * ,r . �d: i is 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 H compliance with San Joaquin County Ordinance No.549 for sewage or,No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. ` �, i , ...q r eye,r 5.. � f.:•,. ? ., 1.'tt`. T1r 4sclt- +? «i 2? �j,r4�,. .'�'� aJ� �1? "��'' '1•`X'� E Job Address 2 SyZ. t '0 t City %pON,'1° Lot'Size PM Owvder's Name 11.4-XIC TTE� /Y/�� Addres's SH�� !� phone Contractor._ / NT/rCy_ 4!Se,yi Address - 2 O•..�'o�r .%Ib,�/ Wlev-70Y H- -L-icense.No_ / 'fig/ ,Phone TYPE OF WELL/PUMP: a ? NEW WELL ❑ WELL REPLACEMENT'EJ ; DESTRUCTION ❑ it ti PUMP,INSTALLATION ElSYSTEM REPAIR ElI. ElI DISTANCE-10 NEA'REST:_SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ".j FOUNDATION r AGRICULTURE WELL ,. OTHER.WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ;CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I," _ r Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac YType of Casin ❑ Public 'i ' g I i Specifications ❑ Other J ❑ pelta Depth of Grout Seal + ❑ Irrigation --Approx.... 'Type of Grout Depth ❑ Eastern Surface_ Seal Installed by Repair Work Done ❑ Type of Pump _ H.P. State Work'Done Well Destruction ❑ Well D,meter - Sealing Material (top 50')- Depth 0'6 Depth Filler Material IBelow 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (Ndseptic system permitted if public sewer is ' �! available within 200 feet.) N, Installation will serve: Residence=, Commercial_ Other ' h Number of living units: f IE Number of bedrooms ,_.. Character of soil to a depth of 31 feet: . s119W IJO SEPTIC TANK ❑ Type/Mfg Water table deth'i L � l,'� n + Capacity p t �•'" PKG. TREATMENT PLT. ❑ No. Compartments G• } �• Method of Disposal Distance to'nearest: Well_` T Foundation -•�: � � � r Property Line f LEACHING LINE ❑ No.''& Length of lines i -X O� Total'length/sizes 7 RLT Distance to nearest:—st: . We1I 647 Foundation -2O'__._..__property Line -SEEPAGEt:PITS ❑ Depth `'-3' ' Size r Number � SUMPS El Distance to nearest: §4We11 Foundation Property Line � DISPOSAL PONDS�� ❑ I� a �-,.- 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 id the performance of the work for which this permit is issued,pl 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 forwhich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must II for all required inspection Cbrrmplete drawing on reverse side. ` Signed r h Title: Date: g'� - 4 OR DEPARTMENT USE ONLY s Application Accepted by Date ' ' �. C S Area Pit or Grout Inspection'by Final Inspectio by ✓ - " /p Date Additional Comments: ' ! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca' 823-7104 racy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT,REMITTED _ CK INFO , . f CASH RECEIVED BY DATE i PERMIT'NO. t ♦ EH 13-24 IREV.1/$51 -., - 3—- --"..+;�,*M^-,_ .-,9:. �:.., i ._...a."„'"-----`.t"-"—•—Y—""'r."'�— EH 14-26 1-