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85-1586
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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85-1586
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Last modified
8/23/2019 10:29:29 AM
Creation date
12/1/2017 2:14:05 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
85-1586
STREET_NUMBER
2418
Direction
E
STREET_NAME
WOODBRIDGE
STREET_TYPE
RD
City
ACAMPO
SITE_LOCATION
2418 E WOODBRIDGE RD
RECEIVED_DATE
12/31/1985
P_LOCATION
ART HOFFMAN
Supplemental fields
FilePath
\MIGRATIONS\W\WOODBRIDGE\2418\85-1586.PDF
QuestysFileName
85-1586
QuestysRecordID
1992238
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. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address W }o `-11 City Lot Sizeo <br /> PM <br /> Owner's Name <br /> Address o?T1� 1 � phone <br /> Contract Address Q r License No" Phon Ea `- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' <br /> i% <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 Y <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout JJJ <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 Itop 56 ' <br /> Depth �� I �T 'ler Maferial (Below 50'1,{ f i ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is ` 1 <br /> - - — -.. - - »• - -. -.. _ --available'within 200 feet.) ' <br /> Installation will serve: Residence_ Commercial Other ; <br /> Number of living units: Number of bedtpoms r .� _ - - ► / <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity °'4No. Compartments <br /> PKG. TREATMENT PLT. ❑ � w �" Method of Disposal j <br /> Distance to nearest: Well Foundation= f Property Line <br /> LEACHING LINE l No. & Length of lines Total length/size o A e <br /> FILTER BED LJ Distance to nearest: Well a Foundation f-6 Property Line <br /> e- <br /> SEEPAGE PITS ❑ Depth Size Number . C' <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ -1) -s . <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 of California." <br /> The applicant st call for req 'red inspections. Complete drawing on reverse side. <br /> Date: <br /> Signed Title: �l U � _ x <br /> t <br /> FOR EPARTM T USE ONLY. : <br /> Application Accepted by' - Date - rea <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH5324;REY.ti l e s} �/IN !— <br /> EH 1426 `7"� Ii,'COY(1 <br /> %-7 �t_ s- <br />
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