83-441 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT T SAN JOAQUIN LOCAL HEALtRI 1601 E. HAZELTON AVE., TrCA PERMIT N0. 5S3Telephone (209) 481 27 3 • [fin � [ 1.1987, DATE ISSUED � i' PERMIT EXPIRES 1 YEAR FROM DATE ISSU E F (Complete in Triplicate) y AL SAS � ��• �- �vv-� ��- D�f— �yc Application is hereby made to the San Joaquin Local Health District for rid/or install the work herein d4 described. This application is made in compliance with San Joaquin Cour inarcce No. 549 for sewage or No. 1862 for well/pump (�1 and.the Rules and Regulations of the San JoaquinfLocal Health istrict. 1 Job Address, D��/� w e � - -•- Owner's Name e A dress Phone Contractor's Name p.License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL W L RE LACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ REPAIR OTHER Lj DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL FITS/SUMPS INTENDED USETYPE OF WELL, r PROBLEM AREA CONSTRUCTION SPECIFICATIONS �•, Industrial ❑ Open,BottomJ ❑ Manteca Dia. of Well Excavation ' �❑'Oome`stic/Private ❑ Gravel 'Pack ❑ Tracy' -' s" Dia.'of Wel l"Casing- ❑ Public ; i ❑ Other ❑Delta Type of Casing XIrrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth Z LJ_ Cathodic Depth of Grout Seal , ❑Geophysical Type of Grout ❑Other Surface Seal Installed by - State Work Done Repair Work Done Type of Pump f L�rb'f�n H.P• 3 Well Destruction ❑ Well Diameter Seaging Material (top 501) Depth i Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION �❑ (No septic tank or seepage pit permitted if public sewer is F-1 I� � available within 200 feet,} Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size S Character of soil to a depth of 3 feet: Water table depth ; SEPTIC TANK ❑ Type/Mfg F Capacity No. Compartments .I PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM c 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 Lined h Number SEEPAGE PITS ❑ Depth I Size 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. , M 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 i; this permit is issued, I shall employ persons subject to workman's compensation laws of.California, I The appli lit must all sr all required inspections. Complete dr wing on reverse side. Ti r ly Title: ��'P S;�:e�"� Date: signed n P TM ENT ONLY � Stk 466-6761 Application Accepted b Area Additional Comments: =` ❑ Lodi 369-3621 Pit or Grout Inspection by Date v7 ❑J Manteca 823-7104 Final Inspection by _ DateL Tracy 835-6385 Applicant -Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CR 95?O1 FEE SASE AMOUNT' DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO 10/$2 500 EH 13-24 REV. 10/82 14-26