Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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. 3 <br /> Job Address ���aZ 1!'2I _ City fie- Let Size PM <br /> Owner's Name C� ( idress 1GK'� tr' "l` PhonC% <br /> I <br /> : ( Contractor Address License No. Phone_ <br /> i <br /> TYPE OF„WEEL/.PUMP: NEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> c PUMP INSTALLATION �.��t' fi alai �1,STEM7._-REPA1R ❑, * OT <br /> DISTANCE TO-NEAREST: SEPTIC TANK” SEWER LINES 4 w. � DISP PROP: L--INE_ <br /> FOUNDATION -- -�-°AGRICULTUR <br /> �` E WEI L - OTHER 1NEL1 -- PITSJ.S.UMPS �7=+-- ^± <br /> INTENDED USE TYPE OF WELL PROBLEM ARE NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing <br /> C Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C <br /> 1-1 Public 0 0 17 D I a Depth of Grout Seal Type of Grout <br /> I 1 irrigation ---Approx. Depth 1 k Eastern �.. . Surface Seal Installed by <br /> Repair Work D L7 Type of Pump r H.P.r f State Work Dane <br /> 4 Well D action C Well Diameter Sealing Material (top 50') <br /> 4 Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION Mo septic system permitted if public sewer is <br /> f available within 200 feet.) 10\) <br /> Installation will serve: Residence `Commercial Other <br /> r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: t Water table depth F <br /> SEPTIC TANK ❑ Type/Mig, Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 3 Method of Disposal } <br /> Distance to nearest: Well Foundation Property Line <br /> v� <br /> LEACHING LINE ❑ No_ & Length of lines Total length/size <br /> FILTER BED �❑ Distance to nearest: ' Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br />.: „RSUMPS„; -��,.Ll; 'Dista nce_to.nearest:t,,,,,:Well,P -.-= Foundation. eroperty,Line <br /> DISPOSAL PONDS ,❑ <br /> I hereby certify that~) 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 C <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 lawsof C "fornia." <br /> The appli ant ust call for all)a uir inspections. Complete drawing on reverse siidJe�, ,,� }Ly <br /> Signed X l Title: � Y L— Date: ^� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Araa j <br /> Pit or Grout inspection by _ /��� Date Final I pection by Date �� <br /> 9pplicant <br /> ditional Comments: r'"� / 40Stk 466-6781 ❑ Lodi 369-3621 ❑ Menie -7104 Tracy 835-6385 <br /> - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED DASD RECEIVED BY DATE PERMIT•NO. <br /> Al <br /> + £H 13-24(REV,1 i sl ? / ] <br /> EH 1426 <br />