89-2697 - Laserfiche WebLink

Home Browse Search

F - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 456-67$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 31700 S. Bird Rd. Lot 27 city Trac Lot Size PM Owner's Name _ J. D, M Address Phone 1 Contractor Hennings Bros. Address 3525 Pelandale Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL V( WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _-1-00-1 SEWER LINES DISPOSAL FLD.1001 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i +' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION 61t ❑ Industrial �❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �pnGfavel Pack Trac Type of Casing PVC Specifications �]KDomesticlPrivate y Bentonite Cl Other ❑ Delta Depth of Grout Seal 100 t Type of Grout F1 Public driller V" I I Irrigation Approx. Depth I l Eastern Surface Seal Installed by - Repair Work Done L-1Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material /top 501 d i Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 l DESTRUCTION 1 l (Noseptic sy t m rented if public sewer is availabInstallation will serve: Residence_ Commercial Other4 ry --- - Number-of diving units:— n— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size fy FILTER HED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ld 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 Diktrict. 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 drawingo verse s' a. Signed X plonni.;?n�cg Rr�, �.---�1 Title: Dater 11-1-89 fi FOR DEPAR ENT USE ONLY k �f/ Application Accepted by Date //rte Area Pit or Grout Inspection by Date Final Inspection by Date 4,. Additional Comments: __ /-54 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-740 ❑ 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 RECEIVED BY DATE PERMIT NO. t. p .+.EH 7321/REV.1/H sYINFO © �_1t"i3- r EH I4-n