89-352 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 00 1601 E. HAZE T ON AVE., STOCKTON' CA 2 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. A Job Address 27200 LEEWARD WAY LOT 98 City TRACY Lot Size PM p Owner's Name G.E. WHITLOCMUHMddress 1 " I 1 13 1 MA R I A N, CT Phone 835-6338— * Contractor H E N N I N G S B R O S _ Address 3,2_F) PF I A N n A I F A 1!F License No. Q CI Q 9 Phone TYPE OF WELL/PUMP: NEW WELL,R] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER M DISTANCE TO NEAREST: SEPTIC TANK 1 OO r SEWER LINES 10 ODISPOSAL FLD. PROP. LINE 10 t 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 12 It Dia: of Well.Casing 611 "Domestic/Private IX Gravel Pack }{ (Tracy Type of Casing P V C Specifications 1`1 Public f] Other F1 Delta Depth of Grout Seal (]O r Type of Grout A-e a :-(1-n i t P._, I i Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by OS, l ,. - Repair Work Done L7 Type of Pump H.P. State Work Done l Well Destruction ❑ Well Diameter Sealing Material atop 50'1 O i Depth t Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION t I (No 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 'f Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size • FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth-I Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C7 i 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. Complet`e�drraawin on to erre side. (tCJt r Signed X _ Y' TitleS,C. yVL4 , Date: \MLXLA FOR DEPARTMENT USE ONLY Application Accepted by Date Z_313 3 Area Pit or Grout Inspection by /C/ Dat Final Inspection by Date Additional Comments: ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 ` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �PERMI'1'NO- +.EH 13-241RE'V.1iHs) EH 14-28 A_,_* /Z3 .