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4200/4300 - Liquid Waste/Water Well Permits
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88-2628
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Last modified
12/7/2019 11:00:59 PM
Creation date
12/4/2017 4:22:36 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-2628
PE
4221
STREET_NUMBER
108
STREET_NAME
CARDINAL
City
STOCKTON
SITE_LOCATION
108 CARDINAL
RECEIVED_DATE
10/03/1988
P_LOCATION
JOSEPH SANCHEZ
Supplemental fields
FilePath
\MIGRATIONS\C\CARDINAL\108\88-2628.PDF
QuestysFileName
88-2628
QuestysRecordID
1678748
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT `= <br /> 1601 E. HAZELTON ON AVE., STOCKTON -CA' <br /> Telephone (209) 466-6781 . <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `'�� Q <br /> (Complete in Triplicate) <br /> Application is haieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance o. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ��{�a <br /> Job Address City uc ` ot Size PM <br /> Owner's Name 0'� S 1�.� (4..&, ddress !��Q�" �La j, y-<Tl Phone r <br /> Contracto a Address V ~�" I ISd� ""C1 tLicense N � Phone ✓✓� <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (-I Public Ll Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth E I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth - - Filter Material elow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITIONDESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) . <br /> Installation will serve: _Residence __ Commercial Other <br /> Number of living units: Numberof bedrooms i <br /> Character of soil to a depth of 3 feet.• Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _ ___— _ - --' --Capacity No. Compartments <br /> PKG. TREATMENT PLT, O Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS ❑ <br /> I hereby certify that t have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San'Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applican t cal fo all required ' spections. Complete drawing on r verse side. <br /> Signed Title: ) �q,"ev� Dater <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date to Area p y <br /> Pit or Grout inspection by Date Final Inspection by � L�s�.. G Date <br /> Additional Comments: Ala., � 4— D e <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-2 TREY.tin51 <br /> EH 1426 <br /> I <br /> 5 <br />
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