Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATION FOR PERMIT <br /> y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r & 1601 E. HAZES T O[V`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 woEicN"k0M&%TAITThWliA didon is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules a f �EMISIES'Joaquin <br /> Local Health District. <br /> Job Address D P. Cit PM <br /> l�rOwner's Name r Address ® Phone <br /> Contract ess License No.X1--2 Phone <br /> TYPE OF WELL/PUMP: NE WELL 1J WELL REPLACEMENT L1 DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 171OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation p/ --Approx. Depth 1 1 astern Surface Seal Installed by _ - <br /> Repair Work Done Le/ <br /> Type of Pump ' H.P. . 14-` — State Work Done AF au A& <br /> Weil Destruction ❑ Well Diameter ) Sealing Material (top 501 <br /> Depth ± Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRlADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) O <br /> Installation will serve: Residence_ Commercial_ Other <br /> , u <br /> Number of living units:.. Number of bedrooms: <br /> Character-oYsoil toWater table depth <br /> depth_Df 3 t: � -- �- <br /> SEPTIC TANK ❑ 'Type/Mfg, �' �k�. '% Capacity No. Compartments <br /> PKG. TREATMENT PLT..❑ �� Method of Disposal,/ <br /> Distance to nearest: Foundation Property�Line <br /> LEACHING LINE ; l j CI No. & Length of 'fes r i Total length/size <br /> FILTER BED EJ Distance to arest: Well _ �.--._-F Fou an Property Line <br /> ir <br /> "i <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line 7 <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 ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> Home owner or lie agentigna <br /> 's sture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any pe on in such nner as to b come su - ct to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the Ilowing:"I ce that i th rf r n 6f the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws California." i ! <br /> The appfi ant m f all re ire i Co rawing on side. <br /> Signed X / Title: r L�`�'�&� Date: Aff" <br /> } FOR DEPARTMENT USE ONLY <br /> ` <br /> Application Accepted by Date_ -� J� Area <br /> Pit or Grout Inspection by Pate Final Inspection by Date <br /> Additional Comments: <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, Silk., CA 95201 <br /> a <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH �} <br /> +.-EH 13-24[REV.t i x 51 �S. ca� C' �� <br /> EH 14-26 <br />