86-1416 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN COAQU7N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (204) 466-6781 DATE ISSUED _ PERMIT EXPIRES I 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 16249 N. Alpine Subdivision Name Owners Name Harvey Berndt Address Same as above Phone Contractor's Name Goehring Pump License No. 309031 Phone 727-5548 TYPE OF WELL/PUMP WORK: NEW WELL U WELL REPLACEMENT ❑ DESTRUCTION �I PUMP INSTALLATION SYSTEM REPAIR }'PC OTHER IJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF ' ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack {] Tracy Dia. of Well Casing Public LJ Other ❑ Delta Type of Casing V Irrigation Approx. Eastern Specifications [f Cathodic Protection Depth Depth of Grout Seal Geophysical This System is used for both Type of Grout U Other domestic & agricultural use. is Surface Seal Installed by N the fee then less? Repair Work Done ❑ Type of Pump Turbine H.P. I State Work Done hauled Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLRTiON LI REPAIR/ADDITION I (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK U Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS Cj Depth Size . Number SUMPS L—I Distance to nearest: dell Foundation Property Line T 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 District. 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 11 not employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hir' g ❑ sub-contracting signature certifies the following: "I certify that in the per fgrmance of the work for which this permit is, I shall employ persons subject to workman's compensation laws of California." The applicant 1 or all required inspections. Complete drawing on reverse side. Signed X Title: Bkpr. 4ate: [� MENT ONLY 0 Application Accepted b A40— r �_� _ ❑ 5t } 4Cvk 78 l,r� 2� Additional Comments: 2 LV }l — -i' il Pit or Grout Inspection b Date �J Manterp 8 3 Final Inspection by t Date ❑ Tracy , 835-, 385 Applicant - Return all copies t ' onmental Health Permit/Services 160 E. Hazelton Ave., P.D. 13 k pllt9, Stk., CA, 9.5201 EFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE .PE NO. IN FD 10162 500 EH 13-24 REV, 10/B2 14-26