Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAl IN LOCAL HEALTH DISTRICTfat <br /> r TTOCKTON, CA l! <br /> 1601 E. HAZE I ON AVEAVE., V <br /> Telephone [209) 466-6781 Z anQB <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED SEp pU <br /> EALl" <br /> (Complete in Triplicate) f%pplication is <br /> ade to the San Joaquin Local Health District for a pe <br /> Application is hereby minstall nd the Rul ���� oft a San Joaquin <br /> rmit to construct andlor <br /> Bance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for w <br /> made in compliance <br /> Local Health District. / PM <br /> City Lot Size <br /> Job Address + Phone <br /> 1 f Address 4 <br /> Owner's Nam + <br /> License No. y Phon <br /> Address DESTRUCTION a <br /> i Contractor WELL REPLACEMENT ❑ <br /> i` TYPE OF WELLIPUMP: NEW WELL ❑ SYSTEM REPAIR ❑ OTHER E3 <br /> -PUMP INSTALLATION �A"' DISPOSAL FLD. PROP. LINE <br /> SEWER LINES _– - OTHER WELL_..— PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK ��— AGRICULTURE WELL <br /> FOUNDATION <br /> TYPE OF WELL PROBL� EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE ❑ Manteca Dia: of Well Excavation Specifications <br /> 't;.yndustrial [I Open Bottom Type of Casing <br /> ❑'Gravel Pack ❑ Tracy Type of Grout <br /> *Domestic/Private n Delta Depth of Grout Seal _ <br /> I'1 Public Cl Other Surface Seal Installed by <br /> I A irrigation --Approx. Depth I 1 Eastern State Work Done <br /> Type Repair Work Done ❑ Te of Pump " � H.P. <br /> I Sealing Material Itop 50'1 f <br /> Well Destruction n Well Diameter �� Filler Material IBelow 50'1 <br /> Depth <br /> tic system permitted if public sewer is <br /> available within 200 lee" <br /> TYPE OF SEPTIC WOflK. NEW INSTALLATION I.1 flEPAIRlADDITION LI DESTRUCTION i o septic <br /> fi <br /> Commercial— Other <br /> installation will serve: Residence <br /> __�-- <br /> Number of bedrooms Water table depth <br /> Number of living units' . <br /> Character of soil to a depth of 3 feet: Capacity��- 'No. Compartments <br /> SEPTIC TANK O Type IMfg Method of Disposal <br /> PKG. TREATMENT PLT.fl Foundation Property.Line <br /> Distance to nearest: Well�� <br /> Total length/size <br /> LEACHING LINE ❑ No. &Length of lines Foundation Property Line <br /> t FlDistance to nearest: Well <br /> FILTER BED I <br /> Number <br /> I 1 Depth - Size property Line -- <br /> SEEPAGE PITS , Foundation <br /> SUMPS Ll Distance to nearest. Well <br /> Yaws, and <br /> DISPOSAL PONDS <br /> ' { hereb certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state <br /> Y <br /> rules and regulations of the San Joaquin Local Health District. <br /> arsons subject to workman's compensa- <br /> to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signatu <br /> censed agent's sigre <br /> in such manner <br /> Home owner or lias tura certifies the following: 'I certiit is issued,1 shall employ persons <br /> that in the performance of the work for which this permit is issue shall <br /> employ any person <br /> certifies the foNowing: "1 certify that in the performance Of the work for which this perm <br /> tion laws of California." ons. Complete.drawing on reverse side. <br /> ]1 6 <br /> r The applicant must all for:all requir inspectiDate: <br /> f <br /> Title: <br /> 1 Signed <br /> Area <br /> FOR DEPARTMENT USE ONLY <br /> O <br /> Date <br /> c <br /> Application Accepted by Date <br /> Date Final Inspection by <br /> Pit or Grout Inspection by Fr i <br /> Additional Comments: ❑ Lodi1369 3621 17 Manteca 823 7104 ❑ Tracy 835-6385 Stk., CA 952D1 <br /> ❑ Stk 466-6781 <br /> Applicant- Return all copies to!1Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO � ,,,., � <br /> � r �JJCJ" /.w <br /> +.EH 13'2 IREV.1/H5) <br /> EH 14-2e <br />