89-163 - Laserfiche WebLink

Home Browse Search

k. .� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE' TI ON AVE_home 209) 466-6781To�I CA Telep PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compiete in Triplicate) application is No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Iication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This APP uin County Ordinance made in compliance with San Jo ti Local Health District, t PM r �— a1 City Lot Size Job Address 3 Phone It.a Address _ J Owner's Name I . Phone3 License No.r Contract �' ' 7 c Address' - DESTRUCTION ❑ '{ NEW WELL ❑ WELL REPLACEMENT ❑ OTHER ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION C] DISPOSAL FLD. SEWER LINES 1---- PITS/SUMPS I DISTANCE TO NEAREST: SEPTIC TANK �-- AGFt1CULTURE WELL OTHER WELL�— FOUNDATION —.—•-- + INTENDED USE TYPE OF WELL PROBL,EM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Industrial Type of Casing_ f DomesticIPrivate ❑ Gravel ❑ Tracy .Pack Type of Grout `t ❑ Delta Depth of Grout Seal �----- I (-I Public Ll Other ' Surface Seal Installed by I i Irrigation �.Approx. Depth 4 I Eastern State Work Done i H.P. cw ` Repair Work Done . Type of Pump ' Sealing Material (top 50.1 Well Destruction 1-1WellDiameter Q i Filler Material (Below 50 Depth '1 available within 200 feet.) I:! REPAIRIADDITION i I DESTRUCTION i I lNo septic TYPE OF SEPTIC WORK: NEW INSTALLATION system permitted if public sewer is � Installation will serve: Residence, Commercial Other --�— Number of living units: Number of bedrooms ': Water table depth Character of soil to a depth of 3 feet: _ Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ f Foundation— Property Line Distance to neatest: lAe-11 -, Total length/size ❑ No. & Length of,lines---�- -» •- LEACHING LINE Foundation Property Line FILTER BED ❑ , Distance to nearest: Well Number Size SEEPAGE PITS l`I Depth Foundation Property Line SUMPS Ll Distance to nearest, Well - DISPOSAL PO ;NDS 1❑-1 I hereby certify that I have prepared this application and that the work will be done and in accordance with San Joaquin county ordinances, state laws, rules and regulations of the San Joaquin Local Health District.g Y compensation laws of California." Contractors hiring of sub-contracting signature employ any person in such manner as to become s 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 she not ubject to workman's certifies the following: "I certify that in the performance of the work for which this permit is issued,l shah employ persons subject to workman s compensa- tion omQen -tion laws of California." The applic l for all required inspections. Complete drawing on reverse side. e� Date: Title: -- Sign ' F DEPARTfNENT USE ONLY � p Data Area Application Accepted by r Date — Pit or Grout Inspection by Date_�� Final Inspection by �0� Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi i 369-3621 Applicant - Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 9520 i CK RECEIVED 9Y DATE PERMIT NQ. FEE AMOUNT DUE AMOUNT REMITTED CASH y )NFO T—n ♦.EH 73.24 IpEv. EH 14-28