Laserfiche WebLink
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. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 yy,, <br /> DATE ISSUED -1�-1"� 1 <br /> r PERMIT EXPIRES 1 YEAR-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 <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San J . Local Health District. <br /> Job Address C)b 3. 21 F Subdivsiion Name T— <br /> ZYffLC Owner's Name AddressbdS ?J �d Phone o� <br /> Contractor's Name License No. x Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑_ SYSTEM REPAIR ❑-ti OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL .FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL QTHER.WEi.L.". PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I J Industrial ❑ Open Bottom Manteca Dia. of Well Excavation <br /> (❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing <br /> w � � <br /> ❑ Public ❑ Other ❑ Delta Type of Casing <br /> Irrigation Approx. ❑ Eastern Specifications ' y <br /> Cathodic Protection Depth <br /> F-11hdPtti � Depth of Grout Seal <br /> ❑Geophysical .., "� ; Type of Grout, <br /> G U Other 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') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RFPAIR/ADDITIONIx I(No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence X Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: 1)e/ r, I►1 St I Water table depth <br /> SEPTIC TANK Type/Mfg f�Yr° � It GoltCY�r,__ Capacity 00 4 i No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation. Property Line <br /> DESTRUCTION <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line - <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I.have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and 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 <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this'permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applic must c f equired inspections. Complete awing on r verse side. i � q <br /> Signed X <br /> d1 Title: �tbJ1 CLvr T Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area f'❑ Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date ❑ Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Envir ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 e }_ 10/82 500 <br /> 14-26 f %7q <br /> Ta , <br />