Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
a. <br />O <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) ,2_19 <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.S'' <br />//// Al,//jj i' .505 .�� & ....,.r�ll'� '� <br />Job Address V4 M-, N ®J Ven + f + V i'tiy� Lot Size PM <br />Owner's Namey(�� r—Cfilfl(Q/1�/CI�� <br />Address iP &q111aAd Phon(200 �� I <br />AMOUNT REMITTED <br />�a�% 7 <br />Contractor <br />�I Address /5W,041agdLicense No Phyl6 C <br />TYPE OF WELL/PUMP: <br />NEW WELL ❑ WELL REPLACEMENT 0CC DESTRUCTION)__,f <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ —OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />❑ Domestic/ Private - - <br />❑ Gravel Pack ❑ Tracy Type of Casing Specifications - <br />('l Public <br />i l Other ❑ Delta Depth of Grout Seai Type of Grout -- <br />I I Irrigation <br />Approx. Depth I I Eastern Surface Seal Installed by <br />Repair Work Done ❑ <br />Type of Pump H. P. State Work -Doyle _ <br />Well Destruction X <br />Well Diameter Sealing Material (top 501 Fn OLf7t"" <br />Depth ' . Filler Material (Below 50'1 -J�h g5&72t <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATION I') REPAIR/ADDITION 1 1 DESTRUCTION 1.1 (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: <br />Residence _ Commercial'_ Other <br />Number of living units: <br />Number. of bedrooms .. <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK- <br />Cl Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />❑ Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />17-1 No. & Length of lines Total length/size <br />FILTER BED <br />❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS <br />I 1 Depth Size Number <br />SUMPS <br />❑ Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS <br />❑ <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. <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 cartif that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br />tion laws of r ' <br />The applicant m st c f a required inspections. Complete drawing averse side. �� <br />Signed X Title: l���C c��IrV.+ Date: <br />R DEP TM! NT USE ONLY <br />Application Accepted by Date Area <br />Pit or Grout Inspection by Date Final Inspection by _ Date�PG- <br />Additional Comments:r <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 Ava., P.O. Box 2009, Stk., CA 95291 <br />+ EH 13-24 (REV. 1/n5) <br />EH 14-26 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CASH <br />RECEIVED BY <br />DATE <br />PERMIT' ND. <br />S? <br />— <br />1 Sri <br />