Laserfiche WebLink
l . ,. <br /> APPLICATION FOR PERMIT tt L n <br /> V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> l r Telephone.(209} 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> 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 <br /> Local Health District. <br /> Job Address 15985 Catkibrid e City Lot Size PM <br /> Owner's Name <br /> Chuck Evane Address 715 n rr Phone 858-2304 <br /> 11290 Vallejo Ct. <br /> ' Contractor Vall@Jo Const, Iltle- Address All License No. 47983S Phone <br /> 9A7-%661 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F] Public n Other C1 Delta Depth of Grout Seal Type of Grout--- <br /> I <br /> rout I i Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. . State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 __2) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION (.1 DESTRUCTION (A (No septic system permitted if public sewer is <br /> 1 _ available within 200 feet.) [",•( <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fest: Water table depth o <br /> C SEPTIC TANK 0 Type/Mfg Cement Capacity unknown No. Compartments <br /> i PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Size I Number <br /> t SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> r DISPOSAL PONDS ❑ <br /> i 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applicant/Vu�stt call for all required inspections. Complete drawing on reverse side. <br /> IST Title: Zetimator Date: <br /> Signed 919/87 <br /> X — <br /> OR DE RTMENfT USE ONLY <br /> w L <br /> Application Accepted by Date r Area Q �/ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> i <br /> ( Additional Comments: <br /> r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> Y �7 2� <br /> + EH 13-241REV.I/KSI S S/ �J-9 <br /> EH 14-2e v <br />