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88-1582
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4200/4300 - Liquid Waste/Water Well Permits
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88-1582
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Last modified
11/30/2019 10:10:14 PM
Creation date
12/4/2017 9:06:51 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-1582
STREET_NUMBER
4908
STREET_NAME
DANA
City
STOCKTON
SITE_LOCATION
4908 DANA
RECEIVED_DATE
06/24/1988
P_LOCATION
FRANK WILLIAMS
Supplemental fields
FilePath
\MIGRATIONS\D\DANA\4908\88-1582.PDF
QuestysFileName
88-1582
QuestysRecordID
1708827
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466 6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <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 2T � � City <br /> Lot Size PM <br /> I��j�/� �, r� <br /> Owner's Name �&L..S�<� Address Phone ,�_L � 47 <br /> Contractor Address k��C7 —�?� License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION ❑ y <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 /> 7`1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout <br /> —.— <br /> I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dane_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTIO I Wo septic system permitted if public sewer is M" <br /> vailable within 200 feet.► <br /> Installation will serve: ResidenceCommercial_ Other v <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" t I I Depth Size <br /> Number <br /> SUMPS ❑ Distance to nearest: Well" Foundation Property Line <br /> DISPOSAL PONDS D <br /> t <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 Diltrict. <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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." - - <br /> The applicant must call for all required inspections. Complete drawing on reverse side. h <br /> Signed X r Title:' 1 - Date: —,<— �*/' �! <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by � _ Date —Z—y2KE7Area <br /> n <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 7 7/1 sY <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ED Manteca 823-7104 ❑ Tracy 835-6385 a <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE <br /> INFO CASH PERMIT NO. <br /> r.EH 13-25{AEV.Ii85) � 1A / f <br /> :IIV;: <br /> EH 14-2 ;2 <br /> r <br />
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