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 Distri{ct. AAp <br /> Job Address 1 01 E. Q1� 1t.YY . City Lot Size PM <br /> I <br /> Owner's Name 1�1� ��f 1L Address i�C) s& , Phone 1 AS— 3 I <br /> Contractoswl-k�;i .t ,� Address��Q ` License No.3ZZ_80 Phone349-5105 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> •; I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavationx• Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f Specifications r f <br /> 1"1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout-- <br /> I <br /> rout_I I Irrigation _.-Approx. Depth 1 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 50'1 <br /> ? Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) \\ i <br /> Installation will serve: Residence b /Commercial— Other' <br /> Number of living units: l Number of rooms a 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTICFTANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ . . -- f f Method of Disposal i R <br /> " Distance-to.-nearest:_ __Well Foundation_._..._�� Property Line tz; - <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well;fZr Foundation to l Property Lineen <br /> :i <br /> SEEPAGE PITS >4- Depth V3 Size l Number- ' <br /> SUMPS Ll Distance to nearest: • - Well � .� Foundation (�r-Property Line <br /> DISPOSAL PONDS ❑ t 1 <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 DFstrict. s <br /> Home owner or licensed agent's signature certifi"es the following: "I certify that in'the performance of the work for which this permil'is issued, I shall not [ <br /> employ any person in such manner as to become subiect to workman's compensation laws-of California." Contractor's hiring or sub-contracting signature 1 <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California.". <br /> The applicantrtA�allllire i9.6 nspections. Complete drawing on reverse side. <br /> T <br /> Signed X—^ Title: �� Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date1 r — Area <br /> Pi or Grout Inspection by Date Z Q • Final Inspection by X21 Data <br /> i <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> ,,+ EH 13-24(REV.I/K5) <br />