90-3152 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ' ! m SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 E PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED !E (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 38511 W. f_inne Rd, city Tracy Lot Size PM Owner's Name J•D• Most COnSt. Address 3941_ AA HOl I v l7I v 17 t �'. , Tracy Phone 93s— Contractor Hennings Bros. Address License No.29Q$4-3 _Phone_ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 120' SEWER LINES DISPOSAL FLD._12_1_+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 Excavation6 u Dia. of Well Casing. X Domestic/Private X1 Gravel Pack ] Tracy Type of Casing PVC Specifications (`I Public L1 Other F1 Delta Depth of Grout SealToo Type of Grout Bentonite ! I Irrigation /_, .Approx. Depth I I Eastern Surface Seal Installed by 1 i"1 ler Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well diameter Sealing Material Itop 50'1 T,_Depth, Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is 1019- available within 200 feet.) Installation will serve: .Residence Commercial Other Number of living units: Number of bedrooms f Character of "soil to a depth of 3 feet: Water table depth E- SEPTIC TANK ❑ Type/Mfg Capacit PKG. TREATMENT PLT. y No. Compartments L1I; Method of Disposal i. Distance to nearest:, Well Foundation Property Line w II } LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ . Distance to nearest: Well Foundation Property Line << SEEPAGE PITS I I' Depth Size Number SUMPS Ll 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 Sari 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." n' The applicant must call for all required inspections. Complete drawing on reverse side. Signed x Hem i ngS Br05. By Title: Date: 11-28-90 n F R DEPARTME USE ONLY / Q I Application Accepted by Date ,` 3a /t� Area Pito Grout spection b Dat Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 369-3621 ❑ Manteca 823-7104 LKTtaciy 835-63A 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 CK RECEIVED BY DATE PERMIT'NO. )NFO CASH �d+.EH 1 �3.2 (REV.tiM5� � i /fH 1�-2a i/ /aS1c)