FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT AN JOAQUIN LOCAL HEALTH DISTR T •^^� c Telephone (209) 46er@i81 ttol 311p �) PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (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.50.9 for sewage or No. 1862 for well/pump and the Rubs and Regulations of the San Joaquin Local Health District. Job Address I I lI/>Y!G l� I �� ' !t{ - f City �r-PCLot Size PM flvorkj Owner's Name 17fVVI 6 ��; Q3235 N/. I t71" Tires Phone ContractorWSuic,marrFLie Address 3�✓3 'r1-f��r�, cense No.s� _Phone TYPE OF WELL/PUMP: NEW WELL;K WELL REPLACEMENT ❑ DESTRUCTION ❑ y,!(✓I1-1, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 6 I?c m'✓ed 1a.1 (,^S 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 2 ❑ Domestic/Private ❑ Gravel Pack @ Tracy Type of Casing 2 4f `� T�LCC- Specifications 11 Public �7 Other KIDi'1r�1�❑ Delta Depth of Grout Seal �`.S-i Type of Grout 1 I Irrigation v2Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of riving units:__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: We Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI 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 ordination, state laws, and rules and regulations of the San Joaquin Local Health D3trict. 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 becwne subject to workman's compensation laws of California."Contractors hiring or aulrcontrecting 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 applicant m st call for all required in. pections 'Co plate drawing on re ansa Signed ! - YV ' Tntle: . Date: 7- FOR DEPARTMENT USE ONLY Application Accepted by ' Date S- 2 Ares (J. Ph or Grout Inspection by Date Final Inspection by Date 4 �L � Am Additional Coments: 1,✓ 7Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7114 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health PerNt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED Cx R D BY GATE PERMWNO. NFO CASH .. 4.25tREV.reel W CH ►-t -� 97 /(�ZS� EH,�ze