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90-2415
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4200/4300 - Liquid Waste/Water Well Permits
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90-2415
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Last modified
2/23/2020 12:52:19 AM
Creation date
12/4/2017 11:42:51 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-2415
STREET_NUMBER
1750
STREET_NAME
EDNA
STREET_TYPE
CT
City
TRACY
SITE_LOCATION
1750 EDNA CT
RECEIVED_DATE
9/11/1990
P_LOCATION
J D MOST
Supplemental fields
FilePath
\MIGRATIONS\E\EDNA\1750\90-2415.PDF
QuestysFileName
90-2415
QuestysRecordID
1722667
QuestysRecordType
12
Tags
EHD - Public
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_ 1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 01-or <br /> 1601 E. HAZELTON AVE., STOCKTON, CA E <br /> I <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SP � � <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wbkuT/Z&ITf> pplication 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 I ZSP t-- - City Lot Size PM <br /> n / <br /> Owner's Name fes" �'�'�~C Address es LV -16 ` Phone <br /> _G. �r Z7 C. <br /> Contractor <br /> wi <br /> Address License No. Y7-9 �Z Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 1�11 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTAN.CE_TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial © Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' &omestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications <br /> {-1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout_ _ <br /> i I Irrigation _.-Approx. Depth [ I Eastern / surface Seal Installed by - <br /> Repair Work Done L] Type of Pump H.P. '/)— State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50') — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I I (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 Depth Size _i Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 4 <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 DiMrict. <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, I shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call i rAl required�spectians. Complete drawing on raver side. <br /> Signed X ___ Title: lam— �Date: <br /> F EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date S �� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 LI Manteca 823-7104 ❑ Tracy 835-6385 <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 PERMiT'NO. <br /> INFO CASH <br /> ♦,EH13-24MEV.I/A5l <br /> EH 14-26 <br />
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