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88-1045
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4200/4300 - Liquid Waste/Water Well Permits
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88-1045
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Last modified
11/28/2019 10:07:27 PM
Creation date
12/4/2017 5:28:34 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-1045
STREET_NUMBER
2443
STREET_NAME
CHEROKEE
City
STOCKTON
SITE_LOCATION
2443 CHEROKEE
RECEIVED_DATE
4/28/1988
P_LOCATION
MAE SUTTLE
Supplemental fields
FilePath
\MIGRATIONS\C\CHEROKEE\2443\88-1045.PDF
QuestysFileName
88-1045
QuestysRecordID
1687002
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> X <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT L <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> . f <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 wellipump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �, ,, <br /> Job Address A4q 3 dI .� 1 Une-_ City Lot Size PM <br /> MAP- f 7 + Q �Q� Phone � 1 ! <br /> Owner's Name � Address <br /> r <br /> Contract rens �d_ �License No. �f� Phone Sa <br /> TYPE OF WELL/PUMP: UNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST- SEPTIC;TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> 1 <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _--Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Bone ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I DESTRUCTION (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 /> SEPTIC TANK ❑ Type/Mfg {Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 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 l I Depth Size _ Number <br /> t SUMPS ❑ Distance to nearest: Well f=oundation 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: '9 certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call lor all recLuired inspections. Complete drawing averse side. Q <br /> Signed X Title: L Date: �u <br /> FOR DEPARTMENT USE ONLY m <br /> Application Accepted by Date Area <br /> Y <br /> Pit or Grout Inspection by Date Final Inspection by Date O <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Ii Manteca 823-7104 ❑ Tracy 835-6385 _..,_ 41 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> `n <br /> INFO AMOUNT DUE AMOUNT REMITTED CCASH RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-24 IREV.r In 51 ](X 10G0 <br /> - EH 14-26 ✓✓✓� zttJJJ LfU 77 .JJ <br />
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