Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
�. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> D <br /> City Lot Size PM <br /> Job Address d <br /> Phone <br /> Owner's Name <br /> Address IF <br /> r r Z Phone�� } ` <br /> 4—Address ;cense No. <br /> Contractor L REPLACEMtNi LJ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELSYSTEM REPAIR ❑ OTHER C3PUMP INSTALLATION K <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing C <br /> ❑ Industrial El Open Bottom D Manteca Dia. of Well Excavation G <br /> Type of Casing Specifications <br /> �omestic/Private 11 Gravel Pack 11 Tracy yp Type of Grout — <br /> f'l Public n Other D Delta Depth of Grout Seal <br /> I I Irrigation .—.Approx. Depth t 1 Eastern f Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> 4e&&ft-- — H P 0— State Work Done d <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth Filler Material i6elow 50') <br /> TYPE OF SEPTIC WORK: NLW INSTALLATION I i REPAIR/ADDITION I 1 DESTRUCTION I I (No Septic BY t 200 feetrn .) if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other z <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK D Type/Mfg <br /> Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <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 I 1 Depth Size Number <br /> SUMPS L1 Distance to neatest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work <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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." ' <br /> The applicant mu for all req 'ed inspections. Complete drawing on reverse side. <br /> Signed X _ Title: Date—!;—"— <br /> F <br /> ate_ — <br /> R DEPARTMENT USE ONLY _ <br /> Date Area <br /> Application Accepted by <br /> ' <br /> Pit or Grout Inspection by Date Final Inspection by <br /> date <br /> Additional Comments: <br /> ❑ Silk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> i EH 13.24(REV.I/H sl <br /> EH 14-26 <br />