Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATION FOR PERMIT p <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209) 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 /> t made in compliance with San Joaquin County Ordinance No.549 for sewageof No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. to ply 3 <br /> Job Address f 1 " � ` # � `�� City Lot Size / �X PM <br /> Owner's Name � " Address Phone <br /> Ir wit«.: ' ,�� % _ S12 W`2 <br /> Contractor +' Address r 3 Ljregse No. Phone <br /> TYPE OF WELL/ UMP --SFW-WfLt CI"'" NVELL REPLACEMENT ❑ v1 DESTRLICTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ � OTHER ❑ <br /> ,STANCE TO NEAREST: SEPTIC TANK SEWER LINES ,� DISPOSAL FLD. - PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _ PITSISUMPS 111 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA COD,S1Ij TION SPECIFICATIONS , s <br /> © Industrial ❑ Open Bottom ❑ Manteca \'Dia. of Well Excavation *- Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy' j Type of Casing 1 ��� Specifications <br /> 171 Public f1 Other ll Delta Depth of Grout Seal -ms`s Type of Grout —. <br /> I`I Irrigation —Approx. Depth l 1 Eastafn Surface Seal Instel el d by <br /> Repair Work Done 12 Type of Pump H.P. ti �'� ^State Work Done=r_ <br /> r l.r <br /> Well Destruction LJ Weil Diameter ' Sealing M t real ,top 501 <br /> Depth f I r Filler Maters I Relow 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITI N l I DMT-RLIG-TIGN-i"] INo septic system permitted if public sewer is <br /> k available within 200 feet.) <br /> Installation will serve: Residence___�Commerciai— O the/-- � ��'� <br /> r Number of living units: Number of bed ooms <br /> ! llr <br /> Character of soil to a depth of 3 feet: ►� Water table depth <br /> SEPTIC TANK OL Type/Mfg � f Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ , 'f f Method of Di�spposa.�ll <br /> //� <br /> Distance to nearest: Well ` '• .. Foundation, Property Line I <br /> LEACHING LINT ❑ No. & Length of tines 4 To�at length/size <br /> �t <br /> FILTER BED ❑ Distance to,nearest: Well Foundation Property Line « 15 } <br /> SEEPAGE PITS 11 Depth yin - Size a_�+>> _� Number i <br /> SUMPS { ❑ Distance to nearest: Well Foundation Property Line ! <br /> DISPOSAL PONDS ❑ `lu W <br /> hereby certify:hat I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,,anc <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 foil nwinW I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- <br /> tion laws of Califa Si21, <br /> I ` <br /> The applicant u t for al requir mspectians. Complete drawing on re rs side. <br /> Signed X ~ ' Title: Date: <br /> f <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date. <br /> ,Additional Comments: <br /> ❑ Stk 466-6781-" 1 O 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 /> L_ <br /> FEE ' AMOUNT DUE AMOUNT REMITTED CK --RECEIVED BY DATE PERMIT.NO. <br /> INFO CASH �jyS <br /> ♦.Elf 17-2,4(REV,i/x b) 9 <br /> EH 14-26 <br />