84-1043 - Laserfiche WebLink

Home Browse Search

I µr APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s'`P 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 20764 Hansen road City Tracy Lot Size 60 acres ' PM Owner's Name Alfred Henriques Address 21222 Hansen road Phone 09-835-8119 Contractor's Name Martin Pump & Supply License No. 360Y-851 Phone 847-0394 TYPE OF WELL/PUMP: NEW WELLt WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSIT�M REPAIR ❑ S��HER El401 DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, * PROP. LINE r FOUNDATION " .., AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1T Dia. of Well Casing 6 5/8 AD Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing steel Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of,Groutbentonite ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by D Repair Work Done ❑ Type of Pump 11,one H.P. State Work Dane v Well Destruction ❑ Well Diameter Sealing Material (top 50') ', X� ST�.�/ Q pj Filler Material (Below 50'1 TYPE OF PTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) I 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 r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 4 .+ Method of Disposal Distance to nearest: Well. Foundation Property Line LEACHING LINE ❑ No. & Length of lines. r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size ' Number SUMPS ❑ Distance to nearest Well Foundation Property Line a DISPOSAL PONDS ❑ 1 hereby certify that I have prepared-this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, acrd 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." i The applican ust call for all required 'Hsps ins. Complete awing on reverse side. Signed Title: Date: FOR DEP 11RENT USE ONLY r Application Accepted by V Date Area Q > Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ><Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 16M E. Ha elton Ave., P.O. Box 2009, Stk., CA 95201 k � FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`ND. INFO +EH 13-24{REV.101831 EH 14-26