83-647 - Laserfiche WebLink

Home Browse Search

_ APPLICATION FOR PERMI, ®� v a SAN JOAQI,;tt LOCAL h'EALTH u1STRICT Ju 19 1601 E. HAZELTOhI AVE., STOC" p CA PERMIT NO. T.eleplore 12091 466-6�r' , " ,r- @ �, �" DATE ISSUED � PERMIT EXPIRES I YEAR FR- DATE ED�� (Complete in Triplicate) Application is hereby-made-'to the San Joaquin Local Health District for a permit to construct and/or install 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 thq Sari,Joacuin V Lo al Health District, JJ t Job Address �.� 1 �n Qu Yn .. Subdivision Name C�4 yytf Owner's Name�Qq, _ M4-Address .Zt/2 4+ � � hone Contractor's Name License No. 2 Phone TYPE OF WELL/PUMP WORK: NEWIWELL L WELL REPLACEMENT [!10" DESTRUCTION 1� V PUMP INSTALLATIO( F-?., SYSTEM REPAIR L OTHER L D W y DISTANCE TO NEAREST: SEPTIC TANK SD.�- SEWER LINES DISPOSAL FLD. PROP. LINE �L FOUNDATION [ AGRICULTURE WELL OTHER, WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /O!t �5 F-1 Industrial U Open Bottom F1 Manteca Dia. of Well Excavation rU Oomestic/Private=~- —[Rtravels'Pack— Tracy — Dia. of Well Casing +' v L♦Public L Other L Delta Type of Casing If� Er Irrigation �Approx. ❑ Eastern Depth Specifications C v + ❑Cathodic Protectiong} Depth of Grout Seal i Geophysical pe of Grout ®�� L Other a✓�L(� urface Seal Installed by Repair Work Done ❑ Type of Pump + W H.P. State Work Done- Well Destruction L Well Diameter - Sealing Material (top 50') _ G Depth t Filler Material {Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION L (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) Installation will serve: Residehce _ Commercial _ Other II Number of living units: Number of bedrooms Lot size I� Character of soil to a depth of:3 feet: Water table depth 5 SEPTIC TANK Type/Mfg Capacity No. Compartments C PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ t LEACHING LINE L No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j' Depth^ Size Number r SUMPS L Distance to nearest: Well Foundation Property Line - l i. DISPOSAL PONDS - Q t I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin county y P P pP ordinances, state ws, and rules and regulations of the San Joaquin Local Health District. Home owner or tens agent''5 signature certifies the following: "I certify that in the performance of the work for which this t permit is i ued, I s all not emplo any per in such manner as to become subject to workman compensation laws of California. Co ntract. s hi ing b-con 6 1 g sig t e certifies he following: "I rtify that in the performance of the work for which this per it is ss d I shat per . subjec workman's compens laws o lifornia." The ap is nt t ll for inspecti ns. Complete drawin reverse Signed Title: Date: (0 fs 4, DR DEPARTMENT USE ONLY Application Accepted by Area s Stk 466-67$1 Additional Comments: Lodi 369-3621 " Pit or Grout Inspection .6y1 Date `p Manteca 823-7104 Final Inspection by% Date //��—�j 3L Tracy 835-6385 i Applicant - Return all opi to: Envircnmertal Health Permit/Services 601 E. Hazelton Ave., P.O. Box 2009,.Stk,, CA 95201 FEE BASE RMOUNT DUE RMOUNT REMITTED RECEIVED BY DATE PERMIT�N/D. ! INFO q3—� I 1 ! -• f _ `7 0 A. EH 13-24 REV. 10/82 _ 1N 500 i 14-26