COMPLIANCE INFO_FILE 6 - Laserfiche WebLink

Home Browse Search

APPLIC TIOINRFOR PERMIT T SAN JOAQUIN HEALTH� {�.p.BoX 20b9 ., STOCKTON, CA 95'�Lbl''.;• ..« .. Telephone 12091 ► yes-3gzo NOV 0 1^1 PERMIT EXPIRES 1 YEAR FROM DATE ISSU,EQVIRONMENTAI_ Fif11,_TIi (Complete in Triplicate) PF.RNy11T/5FRVIGFS 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.509 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. S� Job Address .�L'U7 1511/ �� 1(/ � �_L ��1.q City Lot Size PM Cl ) , v_ i1A<e,-i Ol�flr' Jf N 7f�i4G SC!0, ✓�hona q/G `1'6 - 2 I Owner's Name Y. �/ E%�✓ ��c1f%C �k-�i115 (-d._ Address �l F i Contractor L 1�/ e� Address �� c' i f' llllrl t License No.f 622 - CS 1 Phon S-Ll I ,? TYPE OF WELL/PUMP: NEW WELL/X (;2) WELL REPLACEMENT ❑ DESTRUCTION ❑ -r),51 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER,Br S'"Z DISTANCE TO NEAREST: SEPTIC TANK >SO SEWER LINES > So DISPOSAL FLD.A_ PROP. LINE _A2Z FOUNDATION /L f AGRICULTURE WELL !�_ OTHER WELL_4V4 PITS/SUM PS/� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 16 Dia. of Well Casing f I Domestic/Private Gravel Pack Tracy Type of Casing /'�C� Specifications / F1 Public 1-1 Other fl Delta Depth of Grout Seal Le xx X30 Type of Grout :=f c I I Irrigation �'' Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ N Well Destruction ❑ Well Diameter Sealing Material (top 501 O Depth Filter Material l8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE n No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di3trict. 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."Contractors 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 Cali rnia.1. The applic ust all r uired inspections. Complete drawing verse side. Signed �� r `•v Title. (q�- a1� Date: FOR DEP MENT USE ONLY Application Accepted by Date / Area ?33 Pit or Grout Inspection by Date R Final Inspection by Date J2 Z -7/ Additional Comments: A Applicant • Return all copies to: Environmental Health Permit/Services P.O. Box 2009, Stk., CA 95201 / r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO �� CASH . 01I324(REV.1ihei Q(/ EH 1t M