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86-540
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4200/4300 - Liquid Waste/Water Well Permits
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86-540
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Last modified
9/7/2019 10:17:58 PM
Creation date
12/4/2017 6:06:24 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
86-540
STREET_NUMBER
25079
STREET_NAME
CHRISMAN
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
25079 CHRISMAN RD
RECEIVED_DATE
05/23/1986
P_LOCATION
JEFF DAVIDSON
Supplemental fields
FilePath
\MIGRATIONS\C\CHRISMAN\25079\86-540.PDF
QuestysFileName
86-540
QuestysRecordID
1689128
QuestysRecordType
12
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EHD - Public
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.i± APPLICATION FOR PERMIT <br /> SAN JOAQUiN'' LOCAL HEALTH DISTRICT <br /> I 16Ck E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466--6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete.in Triplicate) <br /> i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> i' <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Dob Address Subdivision Name <br /> l Owner's Name Q-TIFF 0404/10W AddressJAl Phone <br /> Contractor's Name (A[L1IA7R.. p �/S/�� _No. .. •� �� Phone2 <br /> TYPE OF WELL/PUMP WORK: NE4! WELL � WELL REPLACEMENT DESTRUCTION F_ � <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK Q -f- SEWER LINES DISPOSAL FLD. } PROP. LINE <br /> FOUNDATION _'�a)V- AGRICULTURE WELL OTHER-WELL PITS%SUMPS �L/ <br /> i INT,END£O USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS vI <br /> 1� Industrial U Open Bottom [] Manteca Dia. of Well Excavation p �� <br /> , �omestic/Private <br /> ,Gravel Pack �Tracy Dia. of Well Casing � .. <br /> 17 Public F_�Other Delta <br /> Type of Casing <br /> Irrigation Approx. [� Eastern <br /> ❑ Cathodic Protection Depth * Specifications460 <br /> Depth of GroutSeal f <br /> t7 <br /> Geophysical <br />? Type of Grout $ V7Ty/V -- <br />:t F-1 Other - 1 <br /> Surface Seal Installed by <br /> Repair Work Dane FJ Type of'Pump H.P. State Work Done <br /> 9 <br /> E` Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.L1 REPAIR/AODITION U (No septic tank or seepage pit 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 Lot size <br /> Character of soil to a depth of 3 feet: s. ,' Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> e <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line ` <br /> I <br /> SEEPAGE PITS F-1 Depth Size Number <br /> SUMPS CI 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 <br /> ordinances, .state laws, and 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 <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmanss compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that it the performance of the work for which <br /> this permit is issued ] shall employ persons subject to workman's compensation laws of California." <br /> The applicant mu&t 1 fpr 11 required inspections. Complete draw' q on re erse side. <br /> Signed X Title: I Date: 3 <br /> ' FOR EPARTMLPIASE ONLY <br /> Application Accepted by AM, Area Stk 466-6 81 <br /> Additional Comments: Q Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection.by Date L} Tracy 835-6385 <br /> Applicant - Return- all copies to;: Eh.vi:ronmental,rHeai'th Permit/Services-1601 E., Hdzelton.Ave.,, P.O..'8ox 2009; 5tk„ CA 95201 <br /> : . s• t«$ , <br /> FEE 3ASE% AML06T-..`0UE* `W"AMOUNT REMITTED RECEIVED BY N4 "N,*—DATE �+` PERMTT NO. <br /> INFO. J! <br /> lk 0, . .:' ', "`. ,.' ": ' ,rte`+ i„ +� •. +:. �?- ` '-'- �' <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />
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