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85-722
EnvironmentalHealth
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ELEVENTH
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2076
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4200/4300 - Liquid Waste/Water Well Permits
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85-722
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Last modified
11/19/2024 10:18:57 AM
Creation date
12/5/2017 12:42:14 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
85-722
STREET_NUMBER
2076
Direction
E
STREET_NAME
ELEVENTH
STREET_TYPE
ST
City
STOCKTON
SITE_LOCATION
2076 E ELEVENTH ST
RECEIVED_DATE
7/1/1985
P_LOCATION
SOPHIA DIAZ
Supplemental fields
FilePath
\MIGRATIONS\E\ELEVENTH\2076\85-722.PDF
QuestysFileName
85-722
QuestysRecordID
1729408
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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. 1861 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 2 6-7 City Lot Size 6G /` / PM <br /> Owner's Name P P` �!�Wddress / Phone l r 1 -7 5 v <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONINo 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 /> a <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg ' '} Capacity No. Compartments <br /> a - <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well i 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 ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 District. <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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all re d inspections. Complete drawing on reverse side. <br /> -7 �- <br /> Signed Tide: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date --7 Area 0 L <br /> Pit or Grout Inspection by Date Final Inspection by Date lta-A-g-��J <br /> Additional Comments: <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ 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 /> iFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. <br /> + EH%241REY.5/e51 10.00S— <br /> EH 1428 i I <br />
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