WORK PLANS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E: HAZEL T ON AVE., S FOCKTON, CA Telephone (209) -6781 PERMIT EXPIRES 1 YEAR FRC M DATE ISSUED (Complete in Triplj ate} � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This ap ion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address Ci Lot Size X .140 PM Owner's Name kAV6 QtMAV Address Z phone ContractorAjMdAIG AAAT ZW_Address License No. P"ons TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ P SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK46Ar1#AM1nEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROSLEM'AREA, CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7_11Pe �'�� Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tiacy Type of Casing.. C Specifications ❑ Public Other ❑ Detta Depth of Gro t Seal y�r Type of Grout ftolishle ❑ Irrigation -----Approx. Depth ❑ Eastern; Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State W.; Done i Well Destruction ❑ Well DiameterSealing.Material (top 50T dE*, ,K EtJ70�I IRE Depth Filler Material (Below 501 Ve-L _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ IIEPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.! I Installation will serve. Residence— Commercial_ Other Number of living units: Number of bedroom Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacty No. Compartments PKG. TREATMENT PLT. ❑ ! Method of Disposal Distance to nearest: -well ' Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: well � Foundation Property Line SEEPAGE PITS ❑ Depth size- Number SUMPS ❑ 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 ii i accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the UDwing: "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: '�l certify that in the performance:dthe work for which this pern ift is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete;drawing on reverse sid . i t Signed X Title: ' Date: `a arG rvinr�+ r.l riu, F R DE RTMENT US NLY Application Accepted by Date ea " I Pit or Grout !Hsps io y to Final Inspection by Date � r � Additional Comma ❑ Stk 466-6781 ❑ Lodi 369.3621 D Maff..a 823-7 04 ❑ Tray 835-6385 Applicant- Return all copies to: Environmental Health Ttrmit/Services 1601 E. Hazel ton Ave., P.O. Box 2009, Stk., CA 95201, FEE AMOUNT DUE AMOUNTREMITTED RECEIVED BY DATE INFO PERMIT NO. + EH 13-24{REV, i a 5] J� _ 1 —7/H 9 E4-28 "'�