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. HAZELTON AVE.,'STOCKTON CA <br /> Telephone {209} 466-6781 .1Qq <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E�LT�ypCI�N <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. y <br /> Job Address I 175 S i ts u ",V AV at City 6s�4k^1 Lot Size PM <br /> I Owner's Name Address »? C Phone <br /> % � ,l ti fu ti '7 2010 <br /> Contractor's Name License Na. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ,. DESTRUCTION ❑ <br /> )PUMP INSTALLATION ❑ w SYSTEM�REPAIR ®l } � R, OTHER ❑ <br /> TO,NEAREST:kSEPTIC TANK SEWER LINES DISPOSALIFLD. PAOP-.yLINE <br /> ���s"DISTANCE�� •� _ t <br /> FOUNDrATION' " ° �f + '�'• AGRICULTURE WELL; OTHER.WELL_ PITS/SUMPS <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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth Eastern Surface Seal Installed by 1 <br /> Repair Work Done 7!k Type of Pump H.P. .)� + 1•-State-Work-Done-k H Z <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 <br /> Depth Filler Material Melow 501 <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �I <br /> F } 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 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg " T " rCapacity �IV0. Compartments-� \} <br /> PKG.4TR EAlMENT PLTt.�,❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ~ <br /> 4 <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 /> _ .._ . .� ... __�. ,y ,r .. , <br /> ❑- Distance to nearest:— Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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. ' i <br /> Home owner or licensed agent's?signature certifies-the f6ll wing:•"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 sUbjtrct'to-workman's compensa- <br /> tion laws of Cal'ifoi nia." <br />' The applicant t all all requir d spe ions. Complete drawing.on rexerse side. <br /> Signed ' Title: I Date: <br /> FOR DEP TMENT,USE ONLY <br /> Application Accepted byDate PP__1?Y Area D <br /> fea r <br />' Pit or Grout Inspection by Date Final Inspection by Date 2- J <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEf <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. <br /> Y EH W28 TREY.10183! <br /> l <br />