Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATION FOR PERMIT f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTe L� <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA NO <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 /> Job Address gip" � L City Lot Size PM <br /> Owner's NameAC'S Wtt Address Phone <br /> Contractor f�� L�G5)-Address License No.Le_Vkc:�Phone <br /> TYPE OF WELL/P.UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> F1 Public n Other 171 Delta Depth of Grout Seal Type of Grout <br /> I Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P- State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION IX INo septic system permitted if public sewer is <br /> available within 200 feet.l <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. ❑ t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size i <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS 0 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 6e done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health DFsttict. <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' such anner as to become subject to,workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the folio g "I c fy 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 Cal Ifokia" <br /> The applicant required inspections. Complete drawing on reverse side. <br /> Signed X Title: I�}ly>U Date: —Z0 4 <br /> FOR ARTMENT USE ONLY <br /> A <br /> Application Accepted by .9J5r � Date b Area <br /> el <br /> Pit or Grout Inspection by �1 G Data Final Inspection by Date �� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ LAdi 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 /> INFO FEE A UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�NO. <br /> *,EH 13-24 1AEV.V i H 5l 5 t U l I <br /> Eli 14-M O!/ v <br />