Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATION FOR P RMIT <br /> c V- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA co <br /> Telephone (209) 466-6781 9 � <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C c <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 /> 'J `J• ���r ��-.<� City -L v -Lot Size PM <br /> Job Address <br /> /Z rr' arm ��� /� AM/Address � 0 X <br /> Owner _ -✓ ��1C��� — Phone <br /> Contra,to Sr Na rY i PF C'00 0 —License No. ! �2—� Phone <br /> TYPE OF WELL PUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION El <br /> P-INSTALLATIONSYSTEM REPAIR I/ OTHER ❑ <br /> DISTANCE TO NEAREST$EPTIC-TA-NIC—` SEWER LINES /DISPOSAL FLD. -PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation °^ , Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications / <br /> IPublic 1-1Other ElDelta Depth of Grout Seal Type of Grout LJ 1 <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by O <br /> Repair Work Done *;�6 Type of Pump Lt H.P. Y ( T? State Work-Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms + <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <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 laws of Calif <br /> The applic mus all for all q ed ipaction . omplete drawing on reverse side. 3 <br /> Signed Title: Z? rC Datb: "1 <br /> FOR DEPARTMENT USE ONLY <br /> mak. <br /> Application Accepted by Date � Afea � - <br /> Pit or Grout Inspection by Date Fi al Inspection by C42 A O to <br /> A conal Comments: <br /> / Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 835-6385 �- X) 1 a'r5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA..FEE <br /> 9 "' <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-241REV.10!631 <br /> EH 14-26 <br />