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4200/4300 - Liquid Waste/Water Well Permits
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87-2424
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Entry Properties
Last modified
11/12/2019 10:07:11 PM
Creation date
12/5/2017 1:41:33 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-2424
STREET_NUMBER
2224
STREET_NAME
EUCLID
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
2224 EUCLID AVE
RECEIVED_DATE
6/23/1987
P_LOCATION
EMILIO DIAZ
Supplemental fields
FilePath
\MIGRATIONS\E\EUCLID\2224\87-2424.PDF
QuestysFileName
87-2424
QuestysRecordID
1733740
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 L� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 1 <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �J , <br /> Job Address `^ & e e City CYZA Lot Size/X x 5� , PM <br /> I, ss <br /> Owner's Name��,1 �J�0 �L./�A � Address �" -''�� _ Phone <br /> !GOAtFaet r f 4Z Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ a <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 /> 1'l Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth ' i I Eastern Surface Seal Installed by I _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 - <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence____ Commercial_u___ 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 X Type/Mfg Capacity X00 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal , <br /> Distance to nearest: Well Foundation Property Line <br /> R <br /> LEACHING LINE ❑ No. 8 Length of-lines Total length/size <br /> FILTER BED ❑ Distance to nearest- Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L7 Distance to nearest: Well Foundation Property Line <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, 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 o F nia." <br /> The appl' ant mu call for I quires inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: ah 0o <br /> FOR DEPARTMENT USE ONLY <br /> % <br /> Applice ion Accepted by Date Ar !� <br /> Pit or Grout Inspection Date Final Inspection by` <br /> fa7� Al- Y4 y' <br /> Additional Comments: _- <br /> -r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASCK H RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24 Mev.I/R5) <br /> EH 14-28 <br />
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