FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOs TDISTRICT +� 1601 E. HAZELT04W.VUVEa0N, C ` � I Telephone J 34IN PERMIT EXPIRES 1�YEA�,F„RQI,Vfl,J)T&ISSUED Yor a n•1 ito'mom o �! �R' �-ver �tiZ'aT v! , Na ICo I T� t� r„ �.�- �G Sri/ 6oriN�S � {{��nRtpl)g@I�FFH_JQQ�,Tu-Npt lTT�yy„��JII.`I1ES` Q)iNq of e c�lrov► Qwa e Application is hereby made to the San Joaquin Local Health DisA'c.'tv>✓6Y"r�trtl�titti'L`bnsY h QridYl�ft,,all the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �J 'A Job Address �� L 1 V 0.V�++ D T-1 U City S Lot Size '�" YCtCres PQM J -6 / Owner's Name JTDC K C_,0-Vf9CrAddress 12 t/ IN I�i-fl1P Phone - lR- (�etiSe�V��.S �S�$ �N�usf1-r'o.. 1 Contractor �fBN t7 AddressAve. pSe License No. Phone_ $" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SS r DISPOSAL FLO. PROP. LINE oQIO' �J FOUNDATION I�0 AGRICULTURE WELL ? OTHER WELL _L�" PITS/SUMPS _62V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation TF_ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Nen1 P Specifications j 6eN'1- f"1 Public Cl Other CI Delta Depth of Grout Seal 0 "'�33 Type of Grout �!1 - I I Irrigation --Approx. Depth Iv1'^Eastern Surface Seal Installed byExylor�� i oN Geo services' _ Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter -" Sealing Material (top 501 1 O X'T-C$4-(iJ2 Depth 3J� Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 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 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: 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: "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'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 must call for all required inspections. Complete drawing on reverse side. -�} �t � Signed X- j'K�(:f�i & l l • Title: �5 Date: l �`J Z 20 R DEP ENT USE ONLY Application Accepted by /� - Date / Area Pit or Grout Inspection by Date_ Final Inspection<_bWf ' C��i�. Date / Additional Comments: _ ❑ Stk 466-6781 O 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24(REV.i i H 5) 3�• n'Y'7l� �� U lea,.ZZ EH 14-26