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88-411
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CARDINAL
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4200/4300 - Liquid Waste/Water Well Permits
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88-411
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Last modified
12/12/2019 11:00:33 PM
Creation date
12/4/2017 4:23:55 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-411
PE
4216
STREET_NUMBER
221
Direction
N
STREET_NAME
CARDINAL
City
STOCKTON
SITE_LOCATION
221 N CARDINAL
RECEIVED_DATE
02/29/1988
P_LOCATION
CARDOZA
Supplemental fields
FilePath
\MIGRATIONS\C\CARDINAL\221\88-411.PDF
QuestysFileName
88-411
QuestysRecordID
1678544
QuestysRecordType
12
Tags
EHD - Public
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" APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781A7 <br /> , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <br /> (Complete in Triplicate) <br /> 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 <br /> 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 <br /> Local Health District. <br /> Job Address I City Lot Size PM <br /> I Owner's Name Address Phone <br /> Contractor I�LAddress License N 90 1 ag� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 /> M INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 4 ❑ Industrial ❑ Open Bottom `❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private, ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public Cl Other Cl Delta Depth of Grout Seat Type of Grout <br /> I 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ` Well Destruction LJWell Diameter, Sealing Maierial`Itop 5f1'1" T <br /> Depth _ _!-1 • Filler terial [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION^ REPAI ADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other ` <br /> ! Number of living units: Number•of bedrooms <br /> Character of soil to a depth of 3-feet: Water table depth <br /> j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> r� Method of Disposal <br /> ! Distance to nearest: Wel� Foundation Propl:rty.Line <br /> 4 <br /> LEACHING LINE ❑ No. & Length of lines `- Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation .._---_ Property Line <br /> SEEPAGE PITS I'] 'Depth Size [+,Number <br /> SUM S L-i Distance to nearest: WeH /�C3 Foundation [1 Property Line <br /> DISPOSAL PONDS ❑ [ " <br /> 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 <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 applicant must II fo all re red inspections. Compfet rowing on r er e side. <br /> Signed X Title: _C Date: <br /> r ' <br /> or <br /> FOR DEPARTMENT USE ONLY Q� <br /> Application Accepted by A� Date -a l_[Y� - Area <br /> � qDate �Pit or Grout Inspection by Date Final Inspection by_ <br /> Additional Comments: <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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. <br /> +.EH 13-24 tftEV.1 i a sY <br /> EH 14-26 �0 <br />
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