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87-4261
EnvironmentalHealth
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88 (STATE ROUTE 88)
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15500
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4200/4300 - Liquid Waste/Water Well Permits
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87-4261
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Last modified
11/20/2024 9:22:30 AM
Creation date
12/4/2017 11:08:57 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-4261
STREET_NUMBER
15500
Direction
E
STREET_NAME
STATE ROUTE 88
City
LOKEFORD
SITE_LOCATION
15500 E HWY 88
RECEIVED_DATE
11/30/1987
P_LOCATION
R W MERRILL
Supplemental fields
FilePath
\MIGRATIONS\E\88 (HWY 88)\15500\87-4261.PDF
QuestysFileName
87-4261
QuestysRecordID
1735031
QuestysRecordType
12
Tags
EHD - Public
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" APPLICATION FOR PERMIT <br /> h SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �� �' } <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISMx <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 hereinP�scfltrE�C��his application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the I&_Q%1ket � istff the San Joaquin <br /> Local Health Dist�ri,{ct-rl,s� 5�ft> /�Je4 ��Okir `` <br /> Job Address t/'�"�'/1�'t� _ " _- +" S M <br /> ., --,.__ City Lot Size PM <br /> Owner's Name Address _ O,� L �� hone � <br /> Contractor Address icense No. Phone O <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ r� DESTRUCTJON ❑_ <br />..-r--�-�_ �. ".•. � �,e,°-� - -��,� �.�..-.4 <br /> PUMP INSTALLAT N n SYSTEM REPAIR OTHER i] <br /> DISTANCE TO NEAREST: SEPTIC TANK �SEWER LINES DISPOSAL FLD.' { PROP. LINE rn <br /> FOUNDATION AGRICULTURE WELL OTHER WELL t PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEdlFICATIONS t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca'.� Dia. of Well Excavation L�f Dia. of Wel! Casing <br /> .! f t,; {' <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy' ; l -Type of Casing I <br /> yrs g Specifications <br /> F'1 Public 1-1 Other e-� yLl'DeltON-; Depth of Grout Seal--- t ; Type of Grout <br /> 1 1 Irrigation --Approx. Depth l I_Eastern ? Surface Seal Installed _ <br /> Repair Work Done P__`Type of Pump Ji.P. --r (9 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') l �✓ r <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION t.1 DESTRUCTION.[ I. Wo septic system permitted if public sewer is <br /> - <br /> available-within200 feet.) _ <br /> Installation will serve: Residence= Commercial_ Other <br /> "..Number of living units: Number of bedrooms <br /> z <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, Corh6arfinents <br /> PKG. TREATM�NT PLT. ❑ Methodsof Disposal = <br /> Distance to nearest: Well Foundation f, <br /> _ Property Line <br /> ^� ! <br /> LEACHING LINE ❑ No. & Length of linesT al length/size` 4 <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation Property-Line <br /> SEEPAGE PITS!,_____71 1 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property eine t <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,.-an f <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or1icensed agent's signature certifies the following: "1 certify that in the performer a of the work f6r'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 —- t call f all r ired inspections. Complete drawing on re rse side. _ <br /> Signed t Title: 4 ' — <br /> Date:(-���!/ � �T— <br /> FDR DEPARTMENT USE ONLY <br /> Application Accepted by 'D to ri ? Area <br /> Pit or Grout Inspection by Date Final Inspectio by Date <br /> Additional Comments: <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 Avd.i P.O. Box 2009, Stk., CA 95201 <br /> FEE .AMOUNT,DUE� +AMOUNTREMITTEt7 CK, RECEIVED DATE PERMIT'NO. <br /> INFO "-CASA `. <br /> + EH 134+[REV.tin51 <br /> EH 14-26 V � � . <br />
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