Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
r. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ! <br /> Telephone (209) 466-6781 <br /> 'y + 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 described.This application is y <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 rQ r City ��`��� Lot Size PM` , <br /> I �I <br /> Owners Name Q�yfA04iS '� Cc.J AACAddress S+KN I3.Whone ` <br /> m.. c7 S [3 +1 License No. <br /> 11_ Phone 4� M <br /> Contractor �lr Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION' ❑' SYSTEM REPAIR �." OTHER 11'T <br /> DISTANCE TO NEAREST: ,SEPTIC TANK.---.. . --- SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE:OF.WELL,..-. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom T ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r <br /> —E] Domestic/Private 0 Gravel.6ick ❑_Tracy 5ecifications Type of Casing P <br /> f"1-Public i-i Other ❑ Delta Depth of Grout Seal - Type of Grout <br /> I I Irrigation __--Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done D Type of Pump H,P. State Work Done _ �k <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br />` TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION DESTRUCTION l 1 (No septic system permitted if. public `sewer is \ <br /> available within 200 feet.) <br /> ✓ h. <br /> Installation will serve: Residence�' �'Commercial_ Other * '` <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth df 3 feet: ` Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No-:-Compartments a II <br /> PKG. TREATMENT PLT. ❑ Method of Disposal I �� <br /> -Distance-to nearest:—Well Foundation.':%- Property Line <br /> LEACHING LINE ❑ No. &Length,of )rhes —� �� Total length/size <br /> FILTER BED l�Distance to nearest: Well ':. Fo rZdatian' Property Line ` <br /> } QOY!tiisVG - -W" <br /> SEEPAGE PITS I I Depth Size '"+. ►'Number~ <br /> SUMPS ❑--Distance to-nearest: Well� i--^Foundation Property Line 1! <br /> I DISPOSAL PONDS ❑ '- - •` 1 i41, <br /> 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. I <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 tra tin 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 workma``n's compensa- <br /> tion laws of California." �I <br /> The-applicant m t call for all requ2r intpections. Complete drawing on reverse side. } <br /> I <br /> Signed"X Title: - Date: <br /> i FOR DEPARTMENT USE ONLY - <br /> Date 0 Area k <br /> Application Accepted by !�: 1 <br /> Pit or Grout Inspection by Date Final Inspection by Dat 11 r <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 -❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEMOUNT DUE AMOUNT REMITTED CK RECEIVED BY - DATE PERMIT-NO.1 <br /> INFO CASH <br /> d If ) <br /> -EH 13-24{REV.1/851 0 � O� 7 0 <br /> EH 14-28 IF + <br /> i <br />