90-570 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 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 1800 W. Edna Ct. Lot- #6 City Tracy. Lot Size 329'x2891 PM Owner's Name J.D. Most Const. Address 3941 A Holly Dr. , Tracy Phone —6921 Hennings Bros. Address 3525 Pelandale M d. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL LX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES DISPOSAL FLD. 100' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation 12" Dia. of Well Casing 6 CX Domestic/Private IX Grave! Pack IN Tracy Type of Casing _ PVC Specifications F1 Public f7 Other F] Delta Depth of Grout Seal 100' Type of Grout RAn�e__, CC I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by_ 1 Pf Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health Di$trict. 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 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 California The applicant must call for all required inspections. Complete drawing revers side. Signed X Hennings Bros. By Title: Date: 3-14-90 �DEPA TMENT U5E ON �- Application Accepted by D��p_ _. 15_ I G�\ Date Area Pit,or Grout Inspection by Date Date >,Final Inspection by Date430 96 Additional Comments: �]Q' fL � 1 / ❑ Stk 466-6781 ❑ Lodi 365-3621 Ma eca 823-71547 ❑ Tracy 835-6385 Applicant - Re turn al copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 &M Y..p � tr slat ,..(F.-11vf ) l FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT�NO. INFO �7 CASH (] { +.EH13-244REV.r/fly) /7q ®® �p�'� _�5 o l��✓� EH 1428 l�