90-2638 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I (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 23761 VL .Berg 1A10-- - City Tracy Lot Size 34'x400' PM - I Owner's Name Ed Knesek Address 23696 W. Berg Rd. , Trac Phone 835-9173 Contractor' Hennings Bros. Address 3525 Pelandale, Mod. Liunse No. 290813 Phone . 545-1185 TYPE OF WELL/PUMP: NEW WELL{: " WELL REPLACEMENT �' DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK 100 t SEWER LINES DISPOSAL FLD.100'+ PROP, LINE FOUNDATION AGRICULTURE-WELL OTHER WELL--2-E!— PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'r [ Domestic/Private IX Gravel Pack X7 Tracy Type of Casing PVC Specifications f`i Public ED ther Cl Delta Depth of Grout Seal 100' Type of Grout'Bentonite _ (v I i Irrigation If1 '_Approx. Depth l I Eastern Surface Seal Installed by dri I IPr _ �1 Repair Work Done ❑ Type of Pump H.P. State W Done _ Well Destruction V) Well Diameter C2 Sealing Material Itop 50') �� ✓�T�` GN Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i I DESTRUCTION I 1 INo 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 soi!'to a depth-of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f.1 Distance to nearest:' Well Foundation Property Lin.- `l LEACHING LINE ❑ No. & Length of lines Total length/size i f� FILTER BED ❑ Distance to nearest: Well Foundation Property Line l t s SEEPAGE PITS l I Depth Size _ Number SUMPS D 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 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 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 on rev a side. Signed X Hennings Bros. By rifle: Date: 10-1-90 Ri SE-ONLY c Application Accepted by Date l Area Pit GroutIspection DatA 22Final Insp ction by fate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369- ❑ Manteca 8,23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton ve., P.O. Box 2009, Stk., CA 95201 FE INFO AMOUNT DUE AMOUNT CASH C/A�(S�HCK 11 GEIVEO SY DATE PERMIT'NO/. EH t4-26 *.EH 13-24IREV.I/AS)