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88-3089
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4200/4300 - Liquid Waste/Water Well Permits
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88-3089
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Last modified
12/11/2019 10:49:26 PM
Creation date
12/4/2017 5:27:31 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-3089
PE
4221
STREET_NUMBER
2250
Direction
E
STREET_NAME
CHEROKEE
City
STOCKTON
SITE_LOCATION
2250 E CHEROKEE
RECEIVED_DATE
11/18/1988
P_LOCATION
DEAN BARNWELL
Supplemental fields
FilePath
\MIGRATIONS\C\CHEROKEE\2250\88-3089.PDF
QuestysFileName
88-3089
QuestysRecordID
1686120
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT .._ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> ' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1"YEAR FROM DATE ISSUED Nou` '�'<'' <br /> (Complete in Triplicate) <br /> F <br /> fApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de ribed. This apple ation 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 _ Z�D r< �/' G? /I City �r G'I' 'l Lot Size _$*O PM <br /> Owner's Name �/If Gtr 6 4 Address /L Z Z�z X71 J �,p G r 9.�Zy/ Phone ;7--5'7 7 <br /> k <br /> Contractor 0 Address License No. Phone_ <br /> I TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> G <br /> rt. PUMP INSTALLATION D'- SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTUREWELL 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 /> E ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications <br /> s M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by a _ <br /> Repair Work Done D Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION LI DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial—. Other w^ <br /> Number of living units: �_ Number of bedrooms <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. ❑ M�thod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size 1' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS f I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 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 ust call for all required inspections. Complete drawing on reverse side. <br /> Signed X _ �zl,_� � Title: c�`^�1�`c.d Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by aOC,, Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments:1/d- `�. a���4, /7Y V S_i- <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 CK RECEIVED BY DATE PERMIT NO. <br /> a.EH 13-24(REV.t/H 5) .� �_��~O� _3 d <br /> EH 14-26 O j <br />
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