88-2982 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT r r SAN JOAQUIN LOCAL HEALTH DISTRICT A 1601 E. HAZELTON AVE., STOCKTON, CA f Telephone (209) 466-6781 RSC ,e,nr PERMIT EXPIRES 9 YEAR FROM DATE ISSUED ea (Complete in Triplicate) OCT 19 1988 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the} �r 'n descnbed, This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rule �r1 of the San Joaquin Local Health District, pERM1r/S� AL7H Job Address 11495 Van Allen Rd. city. ESCa lon Lot Size VICES PM Owner's Name _D.urval GolneS Address 11495 Vali Allen, Eka on Phone 838-1549 Contractor Hennings Bros. Address 3525 Pe l anda l e Mod. License No. 290813 Phone_545-1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 t 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 Well Excavation Dia. of Well Casing II IX Domestic/Private IX Gravel Pack ❑ Tracy Type of Casing__.._ PVC Specifications I'i Public ❑ Other Il Delta Depth of Grout Seal _ 50, Type of Grout Bentonite _ I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth _ Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is (' available within 200 feet.) Installation willserve; Residence_ Commercial _ Other Number of living units: Number of bedrooms 1 (tt Character of soil to a depth of 3 feet: Water table depth V 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. F-1: 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 l I Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl r) 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 drawin o rev se side. Of Signed X Title: Date: _.- 10-17-88 f FOR DEPA MEN ONLY Application Accepted by / — 3 — Date Area Pit or Grout Inspection by Da" Ite�_3 Final Inspection by Date Additional Comments: 50111 �2� rn ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 8x23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Se'vices 1601 E. Hazelton Ave., P.O. Box 2009, Silk- CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO ASH RECEIVED BY DATE PERMIT*NO. +.EN 14 2B(HEV.r/x 51 / // / /�—� ✓