89-2347 - Laserfiche WebLink

Home Browse Search

T t Hp,LTli Ogg(�N APPLICATION FOR PERMIT ,\tA�0A�`U�n Ocp � L>�t�� SAN JOAQUIN LOCAL HEALTH DISTRICT ,' i nl, cc, 1601 E. HI phone {209} 466-6781 � TON, CA i PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (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 the San Joaquin Local Health District. � ti t Job Address Th oh C �"/ City Ste c o k Lot Size ere' PM Owner's Name SO4t414h 4 Coro . Address 59ZO '"rl`''�� Q "� ' Phone i,erra Pa CiT 1`r. . 1�[�. Ca il of `FOB0 P i,he L A ` 64 t 4343 43 Phone ( � Contractor [C Address icense No. TYPE OF WELL/PUMP: NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER El �- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 2.C! 4t DISPOSAL FLD. PROP. LINE 1' � FOUNDATION SD'Ff AGRICULTURE WELL OTHER WELLLPITS/SUMPS/'70 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ pen Bottom ❑ Manteca Dia. of Well Excavation C Dia. of Well Casing Z M pnpro�mee`t'/Private��I 2favel Pack ❑ Tracy Type of Casing V4. 5;C 1 Specifications F] Pu'blic '19 4J (3 Other VIDeha Depth of Grout Seal TZ t Type of Grout — A@Q� � C I I Itfigation Approx. Depth l I Eastern Surface Seal Installed by rc O W - fl e 0 t c Repair Work Done ❑ Type of Pump 11 H.P. State Work Done n iM CkOlt H4 Well Destruction ❑ Well Diameter ZrSealing Material (top 501 &-VG f � Depth (O S, Filler Material (Below 501 54"d f ack TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION LI DESTRUCTION l I (No septic system permitted if public sewer is available within 200 1eet.l Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Wat table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: a Faun 'on Property Line LEACHING LINE ❑ No. & Length of lines Total length/size \ FILTER BED ❑ Distance to nearest ell Foundation Property Line �l SEEPAGE PITS i1 De Size _ Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PO ❑ 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 i mia." The applic t mut call for r uir d inspections. Complete drawing on reverse* /��Lsiide. ,, Signed . f' f e Title: ,* C I � ,L10 5 I Date: -+ 19 F DEPARTIMENT USE ONLY Application Acc ed by Date Area Pit or Grout Inspection by Dat Final Inspection by Data 3 Additional Comments: ❑ Stk 466-6781 ❑ 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 96201 FEE- _ INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. EH 13-24(REV.i/A sl EH 14-2e i5�;