Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
_ �a /te�awn u.�P.fls <br /> ,. APPLICATION FOR PERMIT a ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Y l_ <br /> 1 < $ 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 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 <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 — 77 City! C Lot Size PM <br /> Owner's Name lj/'� f � �, — Address _Q r'YI ��- Phone <br /> Contract Address icense No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION NC— <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTH ❑ <br /> DISTANCE TO NEA SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE <br /> FO ION AGRICULTURE WELL ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL _ OBLEM AREA CONS ION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mantec ia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type 'n Specifications <br /> n Public Ll Other Delta Depth of Grout Sea Type of Grout — <br /> I I Irrigation _ A Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done 13 a of Pump H.P. State Work Done <br /> Well Destrotion Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WO K: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living uniils: Number of bedrooms <br /> Character of soil to 0 depth of 3 feet: Water table depth <br /> SEPTIC TANK >( Type/Mfg Capacity—J1400 No. Compartments �Z <br /> 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 X Depth =0)gI Size :33 / Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wifl 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 applica t t ca for all-requi inspections. Complete drawing olaeca.., <br /> erse side. <br /> Signed X Y Title:AA - ta.�,. Date: f _ <br /> _04�3FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 7 Awa <br /> Pit or Grout Inspection by Date Final Inspection by Date \ <br /> Additional Comments: g-3 <br /> ❑ Stk 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. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMI7'NO. <br /> INFO hrKn <br /> ♦ EH13-24 1REV.1/H 5) if <br /> EH 14-26 <br />