88-2927 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 Health District, Job Address 16515 Carrolton 'Rd. city Fscalan Lot Size PM Owner's Name PhAlip Francisco Address Phone — Contractor Hennings Bros o Address 13525 P n License No. 29fBJ3 Phone S4 5—11 INS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTU DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK 100E SEWER LINES DISPOSAL FLDCC.r+ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL—45' PITSISUMPS _ INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [\ 11 4 El Industrial 0 Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing XXDomestic/Private XX Gravel Pack 0 Tracy Type of Casing PVC Specifications f`l Public D Other D Delta Depth of Grout Seal 501 Type of Grout Bentonite - I 1 Irrigation Approx. Depth ( I Eastern Surface Seal Installed by driller _ I Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction D Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.I lnstallauo serve: Residence_ Commercial` Other Number of living unt Number of bedrooms Character of soil to a depth o Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method.of Disposal " Distance to nearest: Well oundation Property Line LEACHING LINE ❑ No. & Length of lines Tal length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation arty Line SEEPAGE PITS l I Depth Size Number SUMPS 0 Distance to nearest: Well ' Foundation Property Line + s DISPOSAL PONDS ❑ t ' 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, a rules and regulations of the San Joaquin Local Health District. ! 3 r Home owner or licensed agent's signature certifies the following: "I cortify 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 Sufi-contracting signature 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- tion laws of California." i j The applicant must call for all required inspections. Complete drawind on reverse sid '' I i Signed X TiNe Dal-.- —� —�� D ART ENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by -Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED KSH RECEIVED BY DATE PERMIT'NO. INFO a.EH 13-24(REV,t/x 5) EH 14-26 70