SU0009663 SSNL - Laserfiche WebLink

Home Browse Search

' APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. 1601 r ENAVE., 6780N, CA Telephone (209) 466- DATE ISSUED, ' 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 Sang Joaquin Local Health District. — Subdivision Name Job Address 2 6 yMNE 11 Phone �D T6 Owner's Name fla nl lA�t �CO1� Address 4� L//✓Jvyr Phone Contractor's Name yy v l�„yy>fGT License No. ' f ” ❑ WELL REPLACEMENT ❑ DESTRUCTION[,J TYPE OF WELL/PUMP WORK: NEWiWELL ❑ OTHER PUMP INSTALLATION SYSTEM REPAIR ❑ ❑ DROP. LINE 1, SEWER LINES DISPOSAL FCD. DISTANCE.TD NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION 1 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS teca Dia. of Well Excavation -- Industrial ❑Opeh,Bottom C1Man' Dia. of Well Casing❑Domestic/Private ❑Gravel Pack ❑Tracy - — --`— ( ❑Public ❑Other ❑Dei to Type of Casing ❑Irrigation ?Approx. Eastern ❑ Specifications ' Depth Depth of Grout Seal .--- ( ❑Cathodic Protection I ------ { ❑Geophysical Type of Grout ❑Other 1 Surface Seal Installed by Repair Work Dane QYP Type of Pump, H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing Material (top 501 _ — Depth Filler Material (Below 50') ' o septic tank or seepage pi TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (Navailable wthiif nu200c feetis )- - Installation will serve: Residence I Cortenerc ial _ Other c Number of living units: —L-1. Number of bedrooms _ _Lot size Ac.✓ES / 'r/r } �/�. A",t Water table depth -fD - 12 Character of soil to a depth of 3 feet: _ No. Compartments SEPTIC TANK ❑ TYPe/Mfg �• 1. apacity R Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Property Line Septic Tank Distance to nearest: well �.^Foundation, , Destruction 1' Tatal,3ength/size LEACHING LINE []✓ No. a Length of lines �^ q 8 -•' property Line CD BED Distance to nearest: Well foundation Size SEEPAGE PITS 71 Depth 1 _ - ' SUMPS LJ Distance to nearest: Well Foundation Property Line,•_ ''� '� i DISPOSAL PONDS ❑ I hereby certify that I have prApared this application and that the work wil:i "be done in accordance with San.Joaquin county ' 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed a notsemrloatane certifies in she following:manner as to become111 ysubjactthat ntonworkman4 compensationthe wlawsfof California." permit is issued, ploy Y P Contractor's hitt sub-co ratting signature cert tfies the fo llow5ng: "I'certify that in the performance of the work for whit this permit is d, 1 sh 1 employ persons subject to workman's cumPensat5on laws of California." ' The applica ust cal ilrequired inspections. Complete drawing on reverse side. pate /3 - Signed X CIfC Title: J FD ARTMENT USE ONLY -I Area © ❑ Stk 466-6181 Application Accepted by - ❑ Lodi 369-3625- ' Additional Comments: Date ❑ Manteca 823-7104 Pit or Grout inspection by �� /, , Date '�9A.& Tracy 935-6385 Final Inspection by ,� Applicant - Return all copies to: Environ 1 Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 9520 t1 FEE BASE -UHT- DUE AMOUNT REMITTED. RECEIVED BY DATE PERMIT NO. INFO LA-13'83 1119 a ys( s EH 13-24 REV. 10/82 10/82 500 1 \ 1