SU0004325 - Laserfiche WebLink

Home Browse Search

��APPL CI ATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-E RAZ + C�1vEO Telephone (209) 466-6781 3 �g90 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��`\ `LtiNGC�1�1GE5 (Complete in Triplicate) gqN ��cpLS �Hp1V15I0N Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereQi�` q�*6 application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules av(Uyg¢V twns of the San Joaquin Local Health District. Job Address32LJ6 EAS F2EM041 F ST_ CitX 5 ( "g o ") Lot Size`IOr o00 +P}Z PM 21410 GA-N I No Q,4 N0 V I Owner's Name CH Oven FJ L(. r.A. INO' Address 54N LA if O.V. c* 94583 PhonAls' $(/2-g625- CZ 6 Qa 50-Al ajp. Contractor(+(LJ/ANCr WELL 32f(-L1 W Address Co NCO ICJ7 LJ[I y($ License No.48Z 39 O PhofJ(S)685- 6613 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C1 SYSTEM RE AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES Jr' 0,4r DISPOSAL FLD. PROP. LINE 10 FOUNDATION AGRICULTURE WELL OTHER WA PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Io.h -7- Dia. of Well Casing N ❑ Domestic/Private lid Gravel Pack ❑ Tracy Type of Casing V(� Specifications 0•0(0 >le c.weaf f'1 Public ❑ O her 64 Delta Depth of Grout Seal 6G Type of Grout, 11111/r �tipn p,NG 4�pprox. Depth I 1 Eastern Surface Seal Installed by KVIL44A4¢ 114 ALL .�QI(SCI Al(� - J pair or Done ❑ Type of Pump H.P. State Work Done _ V Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I 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 living units: _ Number of bedrooms 3 Character of soil to a depth of 3 feet: Water table depth U SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line ----1 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 Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "1 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's 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 this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus II all req ui d inspections. Complete drawing on reverse side. N d� Do 9 Date: Signed X Title: r� —r r / , FOR DEPARTMENT USE ONLY 'Ira / `/ / Application Accepted by G� Date � / T O Area 7 3'� Pito ou Inspection by Date dA//• n Final Inspe tion by Date •!3• 7th Additional Comments: /JJfiJ L 3 `""�'� C0`Wt� L44AZ�& ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 WD RECEIVED BY DATE PERMIT NO. NFO . EH 1}N(REV.rixSI /I/9p p EH 1438 - v`