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 /> 4., " . <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in.Triplicate) <br /> � ,� rte,, •�- :, r. ,x _ .,. _ r <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> j lc <br /> Job Address - City Lot Size PM <br /> Owner's Name Address �] '✓� �.0 7.1` C6� W Of!/f Phone 7 b91 <br /> Contractor'.o JRA12Q.1Sff+S.43 Address q Yicense Na._ Sf f Phone `7 G tr <br />' TYPE,OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> / PUMP INSTALLATION ❑­ "�. SYSTEM REPAIR D. OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID. PROP. LINE <br /> FOUNDATION`' F ' 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 /> ❑ Public ❑ Other I - ❑ Delta Depth of Grout Seal Type of Grout. <br /> ❑ Irrigation --Approx.'Depth ❑ Eastern Surface Sea! Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Wel! Diameter, Sealing Material (tap-50'1 <br /> Depth r Fillet Materia )Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence X 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 TANKType/Mfg Capacity-f- No. Compartments <br /> PKG. TREATMENTIPLT. ❑ f I Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. K Length'of lines Total length/size <br /> FILTER BED ❑ Distance to nearApt:,__Well Foundation 9 Property Line <br /> SEEPAGE PITS i ❑ Depth '• Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property 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 JoAuin`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 n <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 following:"I certify that in the performance of the work for which this permit is issued, I shall employ peisons subject to workman's compensa- <br /> tion laws of California." t <br /> .The applicanLmust call for all required ' s ctions. mplete drawing on reverse side, <br /> SignedTitle: Date: <br /> i FOR DEPARTMENT USE ONLY <br /> Application Accepted by - 4y ' Date Area <br /> Pit or Grout Inspection by Date Final Inspection b, <br /> Da <br /> Additional Comments: a <br /> N .t "^ j d # <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., 136(200%.Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED.BY DATE PERMIT"No. <br /> + EH13-24fREV.Iia6) <br /> EH}426 <br />