FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN LOCAL HEALTH DISTRICT - •.fCp1 r err —n. y...- , ..-'l.r rre-.u� \,>� Telephone (209) 469•@7@1 {fUi 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 compkance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wag/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address I 11 ''II ' I/1f L L- INS �� ' f�" City I rPC"I Lot Size PM <{ Owner's Name TyI t �CU� Address �Z35 �7"" r I Phone �c.l� r t5'uiummko CS'J — 5Iv Contractor W e{` -L?? q� Address 3233 Tj'(�yclz,ic( , License No.sE Phone TYPE OF WELL/PUMP: NEW WELL,& WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ ID tivled (9-1 L)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 Zr Cl Domestic/Private ❑ Gravel Pack n�@ Tracy Type of Casing off 40 Fyc Specifications } ❑ PublicC�' Other �Q'Ir�l•7y fT Delta Depth of Grout Seal "r l Type of Grout WW-7 l , I I Irrigation 2CApprox. Depth k� I I Eastern Surface Seal Installed by Repair Wok Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character at 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: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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 rulas and regulations of the San Joaquin Local Health D$trct. Home owner or licensed agent's signature certifas the following: "I certify that in the performance of the work for which this permit is issued, 1 shag not employ any person in such manner as to become subject to workman's compensation laws of California.-Contractors hiring or sub-contracting signaryngnaturt certifies the following:"I certify that in the performance of the wok for which this permit is issued,I shag employ persons subject to workman's co - tion laws of California." The applicant must call for all required in pections 'Co plate drawing on reversal side., / -m Signed YV- Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date S' Z Area (� Ph or Grout Inspection by Date F-mal Inspection by Date AL �2.— Additional Comments: 1 J❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 Applicant - Return all copies to: Environmental Health Pemtit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 P�T ' FEE AMOUtlT DUE AMOUNT REMITTED OK J INFO yq}�/ rqj y/5��.� CASH R ED BY DATE 1 GPERMR'NO. ..EN liar fREV.rrxs� ,�n `� I -w � IIY�OI 3 '� 'y(/ EH 14M