89-2499 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT erl� r 1601 E. HAZE i ON AVE., S70CICTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED i OCT f � 't (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tJ�wor f�e�rn described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the'R I tend I$gauTiooh Bothe San Joaquin Local Health District. �iJ �rs7�M) p�/(/ / S- win«r/_RVX=E a,D. ra'y 23�-ulrwop_Ali}/' `TRi41 r'��V� Job Address 117"/� hGH A17 --- - City Lot Size�c�.I_�.1�__. PM i Owner's Name DFE-.Od- Cfllf27' Address.2� 2W 400Ey9f1/.(I',� Phon61�Zia__218-2a v 94-4,4 Conti a c I o6A1WA7-rP_aegUA '� Address .S- rTl License No31.��- Phone I TYPE OF WELL/PUMP: NEW WELL G WELr REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:,SEPTIC TANK cC3F% SEWER-LINES .- =:DISPOSAL-=FLD36VF_7-PROP. LINE / FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Ea Manteca Dia- of Well Excavation l2 Dia. of Well Casing' it bA,Domestic/Private 'K Gravel Pack ❑ Trac Type of Casing p 6 F�Specifications f f'1 Public n Other X-Delt Depth of Grout Seai Type of Grouta�/l1� I k Irrigation 1-211--Approx1 Depth i I Eastern Surface Seal Installed by L+� Repair Work Done ❑ Type of Pump H.P. State Work Done_ f• Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r' TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION 1-1 DESTRUCTION I 1 (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 ❑ T I ypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method.of Disposal r` Distance to nearest: Well Foundation Property.Line f f t I ��C,,, LEACHING LINE ❑ No. & Length of lines jr Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line , t SEEPAGE PITS _ f l Depth Size' _ Number'— SUMPS umber'SUMPS l_1 Distance tp nearest: -Well Foundation Property Line'' DISPOSAL PONDS ❑ r' a 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 Di$trict. 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 applicapt-gnus II or all r ired inspections. Complete drawing on erse id . � f Signed X Title: Dare: F FOR DEPARTMENT ONLY f Application Accepted by Date/ Area �! Pit or Grout Inspection by i Date � _ Final Inspection b Date 10 - 7 - d'r? Additional Comments: eSe {0 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit./Services 1601 E. Hazelton Ave., P.O. Box 2009, 51k., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH 41 RECEIVED BY DATE[ PERMiT'NO. ♦.EH13-24(REV.i/n51 7n,�0 Ia �t J(��J�—/i y �'�(^?jCs� EH 14-25 11`l / I f C !