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. _ <br /> Lot Size PM <br /> Job Address <br /> rP a c3 1 r �� z` City <br /> A vD,-45OV �� Address �-i'��!( HJAr-25�--/4 Phone <br /> Owner's Name <br /> rliC License No Phone <br /> Contractor iirf � --Address o <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER 13 <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of, Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ DomesticIPrivate ❑ Gravel Pack ❑ Tracy Type of Grout <br /> f'l Public ❑ Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 0 <br /> Depth Filler Material (Below 50'l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Il REPAIR/ADDITION i I DESTRUCTION ( I ( o se <br /> NailabPe�within 200 feet.) <br /> c system kned if public sewer is <br /> Installation will serve: Residence I Commercial Other �. <br /> Number of living units: -/— Number of bedrooms—13 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg,' <br /> Capacity /�� No- Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. El <br /> � <br /> Distance to neatest: Well _— Foundation_t�� — Property Line !w t <br /> Total length/size y �� <br /> LEACHING UNE No. &'Length of lines 'r 7- 7- <br /> FILTER BED L1 Distance to nearest: Well /3 Foundation Property Line r <br /> SEEPAGE PITS It Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <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 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 /> signature <br /> employ any person in such manner as to become subject to workman's compensation law <br /> s of California." Contraceonslsub suring bject to wo�kmantlscompensa <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p I <br /> tion laws of California." <br /> The applicant must call for at requir dinspec tions. Complete drawing on reverse side. U <br /> Signed X f <br /> Title: Date: <br /> p PARTM USE ONLY <br /> Application Accepted by <br /> Rate tea / <br /> Pit or Grout Inspection by <br /> Date Final Inspection b 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, Stk., CA 95201' <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> +.EH 13-24 IREV.I I R 51 <br /> EH 14-28 <br />