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87-1872
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4200/4300 - Liquid Waste/Water Well Permits
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87-1872
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Last modified
11/6/2019 10:07:32 PM
Creation date
12/5/2017 1:04:03 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-1872
STREET_NUMBER
16822
STREET_NAME
ELSHOLZ
STREET_TYPE
RD
City
RIPON
SITE_LOCATION
16822 ELSHOLZ RD
RECEIVED_DATE
05/11/1987
P_LOCATION
CATHERINE MAXHAN
Supplemental fields
FilePath
\MIGRATIONS\E\ELSHOLZ\16822\87-1872.PDF
QuestysFileName
87-1872
QuestysRecordID
1731143
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR.PERMIT <br /> " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 9601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED.,,,,,, <br /> -— ----a: J <br /> F � 10Complete 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.. M .," #, ` i f,+J Vt r.. m 7, <br /> Job Address � - �--' �� iJCity P.lP6 . -Lot Size PM ... <br /> rc <br /> Owner's Name __� /1 ��✓ �/y` ess _�(� �f i�.S�T4.C,� Phone <br /> Contractor's Name epj�icense No. 3917 /6� Phone591_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION a� SYSTEM REPAIR ❑ OTHER ❑ - t <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 w <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing + <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> t <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Jurface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done I <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth' ' Filler Material (Below 50.1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> -w - <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. I <br /> Distance to nearest: Well Foundation Property Line e <br /> LEACHING LINE ❑ No. & Length 6f lines Total length/size y <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 '"" •_._, .-.=� r L �.. <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work-will be dome 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 st II fgr aq requi inspe ns. mplate drawing,on gewqrse sid . �t <br /> Signed Title: Date: 41 J <br /> 0/7 FOR DEPARTMENT USE ONLY y; <br /> R . _ <br /> Application Accepted by Date f r Y 7 Area �J <br /> Pit or Grout Inspection by bate Final inspection by n 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 Ave., P.O. Box 2009, Stk., CA 95201 x, <br /> INFO <br /> p AMOUNT DUE AMOUNT REMITTED CASH <br /> 3 RECEIVED BY DATE PERM17"NO. <br /> +EH 13EV. <br /> 24'-IR ',0/ax �� <br /> EH,4.20 %� , <br />
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