Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATION FOR PERMIT q 3 0 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 <br /> E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ' <br /> 89 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAR 2 C' �� <br /> (Complete in Triplicate) lVVi4 ONMENTAL i�EALTH <br /> FERIA l�14010 is <br /> Application is hereby made n the San Joaquin Local Health District for apermit o. 1862 for we 1/nstruct dpumlp and the Rules and IR Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.548 for sewage <br /> Local Health District. J <br /> Q 6., City f/ Lot Size PM <br /> Job Address t <br /> Phone L_—Y-- <br /> Owner's Name ir Address <br /> Ie � .l am Y License Nol� —Phonb <br /> Contractor 11� t` Address <br /> TYPE OF WELL/PUMP: NEW WELL El <br /> REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION C3SYSTEM REPAIR ❑ # OTHER L) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LkNES- <br /> pISPOSAL FLD. PROP. LINE <br /> FOUNDATION 't AGRICULTURE WELL OTHER WELL PITS/SUMPS t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 4 CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 7 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic I Private O Gravel Pack ❑ Tracy Yp <br /> F1 Other F1 Delta °"+ Depth of Grout Seat Type of Grout <br /> I-1 Public 11� 0 <br /> I I Irrigation .Approx. Depth I l Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump � � H•P. Q 0 State Work Done <br /> I Sealin Material (top 50')Well Destruction ❑ Well Diameter 9Depth I .� . - %; Filler,Material-(Below-50`)-TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I alvailabptic sy t 20em 0(mined it public sew ; <br /> installation will serve: Residence Commercial_ Other t. ! <br /> Number of living units: Number of bedrooms ; <br /> r ; Water table depth <br /> Character of soil to a depth of 3 feet:`' t <br /> k Capacity No. Compartments SEPTIC TANK ❑ TypelMfg <br /> I Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> f Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. A Length of lines Total length/size <br /> f"° <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line: E <br /> I AE <br /> SEEPAGE PITS I 1 Depth Size Number <br /> s <br /> SUMPS Cl Property Line <br /> Distance'to nearest: Well _ Foundation --- . <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." Contractor's <br /> or suto workman b-contractIs compensa- <br /> paturb <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ psubject <br /> tion laws of California." <br /> The applica us call forarequired inspections. Complete drawing on reverse <br /> Signed X <br /> Title: i Date: r <br /> FORD ARTMENT USE ONLY <br /> v Date 0 Area <br /> Application Accepted by <br /> t Date Final Inspection by <br /> Pit or Grout Inspection by • 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.Q. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY OATS PERMIT'NO. <br /> I FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> 6 +.EH 13-21(REV.1 i H 51 <br /> L -EH 1426 <br /> A <br />