My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
90-2661
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
D
>
DIVISION
>
5129
>
4200/4300 - Liquid Waste/Water Well Permits
>
90-2661
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
2/27/2020 10:15:55 PM
Creation date
12/4/2017 10:09:23 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-2661
STREET_NUMBER
5129
STREET_NAME
DIVISION
STREET_TYPE
RD
City
MANTECA
SITE_LOCATION
5129 DIVISION RD
RECEIVED_DATE
10/03/1990
P_LOCATION
JB WILSON III
Supplemental fields
FilePath
\MIGRATIONS\D\DIVISION\5129\90-2661.PDF
QuestysFileName
90-2661
QuestysRecordID
1715669
QuestysRecordType
12
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
2
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
I <br /> APPLICATION FOR PERMIT <br /> + SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> I PE MIT EXPIRES 1 YEAR FROMDATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in co licence with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1. <br /> F <br /> Job Address City Lot Size/Acreage <br /> i <br /> Owner's Name TVAddress PhoneAnay <br /> Contractor,4 (`-_�!a%1�CJ AddressLicense No. Q ,Phone G <br /> TYPE OF WELL/PUMP; �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C7 SYST,EM REPAIR C] OTHER Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEIPTIC TANK SEWER LINES # DISPOSAL FLD, PROP. LINE <br /> il <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i r <br /> ❑ Industrial C] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> d <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F) Public A Other n Delta Depth of Grout Seal T <br /> YPejof Grout - <br /> I # Irrigation I�Approx. De th 11 EasternSurface Seal Installed by j <br /> r Repair Work Done Type of Pump H.P. J7ll���� _ State WorkI Done <br /> I <br /> Well Destruction ❑ Well,Diameter Sealing Material & Depth <br /> F?e11 W <br /> pth Filler Material & Depth _ _. _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-1 I REPAIR/ADDITION I I DESTRUCTION I I fNo 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 <br /> PKG. TREATMENT PLT, No. Compartments <br /> C} �I� o ,• '• . , '' w Method of Disposal,' <br />, Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines - `~.Total length/size <br /> FILTER BED ❑ Distance to nearest{ r Well 4 Foundation i y Property Line <br /> h 'IMS 1' 1' ' <br /> SEEPAGE PITS I I De pth Size <br /> --Number <br /> °� <br /> SUMPS LI Distance to nearest: Well• Foundation Property Line t <br /> DISPOSAL PONDS El �� . <br /> I hereby certify that I have prepared this applicatiori'and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and,regulations of the SaPPJoaquin county <br /> Home owner or licensed agent'isignature.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 certifythat in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California.' <br /> P p y persons subject to workman's compensa <br /> The applicant r2usl call r all required inspections. Complete drawing on r e sid . <br /> Signed X ,11. , Title: <br /> Date: D <br /> FOR QVARTMENT USE ONLY ? <br /> Application Accepted by Date yea <br /> Pit or Grout Inspection by II Date-� Final Inspection Date <br /> Additional Comments: <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> GASH <br /> « EM 13.24 IREy.i i n 51 <br /> EH's4•Ta <br /> �N G <br />
The URL can be used to link to this page
Your browser does not support the video tag.