SU0012894 - Laserfiche WebLink

Home Browse Search

1]]�� rJ(A_- A10UAPPLIiCA.TIrONrO-, {1Jr�V'S) N JODQL1�. LOCO:_ r:�-,L10, J,� RI4i flflif 1n01 E. HAZELT01i ,4'JL., STfi[:r:TC'P�, CFi PERMIT NO. Telephone (209) 466-6781 PERMIT "c:?PIRES I YEAR FROM0,'lTE ISSUISSUE[) DATE ISSUED (Complete in Triplicate) aOM( Application is hereby made to the San Joaquin Local Health District for a permit to construct a1�;,n�s£37+T �rN,J�erein described. This application is- ade in compliance with San Joaquir County Ordinance No, 549 for sewage or No. 1862 for well/pump and the Rules and Regulation the San Joaquin ! cal Health District., 1 T Job Address � �' J n'/' c' �' ric '�t Subdivision Name _ I Owner's Name z> / jy Address '� } .y� j ' Phone r s 4 Contractor's Name sl Y' ,g -',� License No. Phone r , i TYPE OF WELL/PUMP WORK: NE1a.WELL- 7'X f WELL REPLACEMENT ❑ DESTRUCTION U PUMP,'INSTALLATION ,( }. SYSTEM REPAIR OTHER Li DISTANCE TO NEAREST: SEPTIC TANK �,�_ SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom Manteca Dia, of Well Excavation J �.,5j.Doniestic%Private. Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other - [_] a Delti) / V Type of Casing Specifications❑ Depth Cathodic Protection p � ! Geophysical Depth of Grout Seal ❑Other Type of Grout s Surface Seal Installed by Repair Work Done ❑ Type of Pump ,11� H.P. State Work Done Well Destruction ❑ Well Diameter GSealing Material (top 501) _, x- Depth _�rr- _ Filler Material (Below 501) ; TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j f (No septic tank or seepage pit permitted if public sewer is C � Installation will serve: Residence _ Commercial Other available within 200 feet.) Number of living units: . Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth 1, 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 ❑ No, & Length of lines Total length/size `y FILTER BED Distance to nearest: Well Foundation Property Line \� SEEPAGE PITS Depth Size Number /(} SUMPS Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS D 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. i Home owner or licensednt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i s all n, t employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hiring r SuAll signature certifies the following: "I certify that, in the performance of the work For which this permit is issu d, sh 11 emp oy per s subject to workman's compensation laws of California." The applicant mus 1 ror. 1 r §nspections. Complete drawing/or reverse side. , Signed X C Title: �rf," Date-, DEPARTMENT U5E ONLY 10-2-3 Application Accepted by Area 44 Stk 466-678 Additional Comments: —T— Lodi 369-3621 Pit or Grout Inspection by Date * _1_e ❑ MaX_ nteca 823-7104 Final Inspection by ~ Date —t L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT JUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO `g�' _ r ' � ' EH 13-24 REV. 10/82 10/82 s00 14-26