85-5 - Laserfiche WebLink

Home Browse Search

APPLICATION,FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. =HAZETON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES.'LYEAR FROM DATE ISSUED (Complete,in Triplicate] 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 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 Local I aith District.. t ^�� r,9,; f. - W. r 'I I I � / � Job dress CJI.w_ - _ r ~ "w' City AdLot Size.:w X2%7 PM F� Owner's Name >'.t�'S/C /C��j� Address Phone t Contractor's_Name �'7�a_o/T G_1 7._ f,ye-- License No. _ 70 8 _ _Pho_ne 83 S TYPE OF WELL/PUMP: ill' NEW,WELL V ,i WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ " , SY TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /CSO SE ERILINE 4��l1 DISPOSAL FLD. PROP. LINE ! FOUNDATION' AGR ULT E WELL i"OTHER WELL PITS/SUMPS » INTENDED USE TYE OF WELL PROAP. ?5 STRUCTION SPECIFICATIONS ❑ Industrial ❑ Ot.n Bottom .❑ Mof Well Excavation Dia: of'Well Casing 16 Domestic/Private If Gravel Pack ti�Tof Casing �T 4 Specifications ❑ Public ❑ Other ❑ Dh of Grout Seal $'� r"�+`a�r Type of Grout_❑ Irrigationpprox. Depth ❑ Ece`Seal Installed byRepair Work Done ❑ Type,.bfPump�� 4 E State Work Done Well Destruction ❑ Well Diameter Sealingf tectal {top 50') Depth a F11I`er Material'{Below 50,)k �TYPE OF SEPTIC WORK: NEW INSTALLATION •REPAIR/ADDITION ❑ DESTRUCTION EI (No septic system permitted if public sewer is 'I� pL k` i {s'��, available within 200 feet.) Installation will serve: ResidencCommercial__'Other� '" '"�"`� Numberf living units: umber of bedrooms 3 A. Character of soil to a depth of,3:feet: Water table depth �_-SfPTIC TANK TUI/Mfg 1 Capacity No. Compartments {-� PKG1 TREATMENT.PLT. ❑ , = Method of Disposal w l r '.Distance to nearest: Well Foundatlon, s� Property Line LEACHING LINE ❑ No. & Length of lines �� ..y: .._ �- Total length/size f �I FILTER BED ❑ Diktance to nearest; Well ?Foundation Property line ri L SEEPAGE PITS �` ` t';0 Depth ' 'v ^Size V — Number r 'SUMPS y ❑ -Dlktance to nearest: Well FoundationF - Property Line DISPOSAL PONDSR ❑ Il� 1.--•y --. \. f...- \' `C Thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances;,state laws, and rules and regulations of the Sari!boaquin Local Health District.• )4 _ ` Home owner or licensed agent's signature oertifies the following: "I certify that in the'performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatur® 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- tion laws of Californi .'e ;� T - - a - �` The applicant mu c fo II luire nspe mplete drawing on reverse side. { 1. !Ih rfi •�� p Signed Title: Date: EPARTMENT USE ONLY r , 0;7 6 Application Accepted by Date "� Area Pit or Grout Inspection by ' Date nal Inspection by Date Additional Comments: - ❑ Stk .466-6781 + p Lodi 369 3621 i- ❑ Manteca 823 7104 - Tracy 835 6385 Applicant- Return ail copies to: Environmental Wealth Permit/Services 1601 H elton Ave., 0. Box 2009, Stk., CA 95201 FINFO AMOUNT DUE "+AMOUNT REMITTED' CK-4 .s RECEIVED BY# , DATE PERMIT'N0. 11 p k �+EH 1&24IREV 10/831 - EH 1426 t ' r