90-2905 - Laserfiche WebLink

Home Browse Search

{ APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRIC.T� r T N CA O A E�I ON AVE. STOCK0 � 1601 E. W Z /� Telephone (209) 466-6781 ,4.` �jL PERMIT EXPIRES 1 YEAR FROM DATE ISSUE� , �C� tg'� (Complete in Triplicate) ��s( �q tWig Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work 15€ j1C ibed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an r11 (oqs of the San Joaquin Local Health District. (� l-CC3't� ' �]�2 ,;1" �; y 73 Job Address City Lot Size PM Owner's Name Address o _ Phone Contracto Address [� �T ' icense No, -2& Phone t. TYPE OF IWELL/PUMP: F NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ L# - :,-OTHER X DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C INTENDED USE TYPE OF.WELL -~PRO9LEM AREA CONSTRUCTION SPECIFICATIONS �--_ •� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing •- 4f,l- r D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications Public ❑ Other 'I- ❑ Delta Depth of Grout Seal ) Type of Grout _ % 1 1 Irrigation --Approx. Depth I I Eastern Surface Seal installed by t Repair Work Dane ❑ Type of Pump H.P. 5t�to Work Done trl,� Air Well Destruction ❑ Well Diameter Sealing Material Itop 50') l•• Depth - Filler Material {Below 50') r I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i-I DESTRUCTION I 1 (No septic system permitted if public sewer is I E available within 200 feet.) Installation will serve:- Residence_ Commercial— Other Number Fof living units: Number of bedrooms r Character of soil to a depth of 3 feet: I Water table depth ' SEPTIC TANK .❑ Type/Mfg Capacity No. Compartments 'PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ACHING LINE ❑ No. & Length of lines ,Total length/size v� FILTER BED ❑ Distance to nearest: Well Foundation Property Line T; ` t -4 SEEPAGE PITS --,. -I 1 Depth Size Number ,SUMPS LL CI 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 I i rule`s and regulations of the San Joaquin Local Health District. i i I }'dome 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 1 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 1 ji certifies the f Ilo ing: "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 ornia.' j f! The applimust call for ail a wired inspe I ns. omplete drawing o rev side. t I Signed X Title: Date: Y�" �— � ' C S R DEPARTM USE ONLY1 r _ Application Accepted by � Date re Pit or Grout Inspection by Date Final Inspection b i Additional.Comments: f �' ❑ Stk 466-6781 - ❑ Lodi 369-3621 ❑,Manteca 823-7104 ❑Tracy 835-6385 Applicant c Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +-EH13-24(REV.ti8s) EH 14-29 I -