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88-2771
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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88-2771
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Last modified
12/8/2019 10:46:04 PM
Creation date
12/5/2017 3:45:20 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-2771
STREET_NUMBER
3906
Direction
E
STREET_NAME
FOURTH
STREET_TYPE
STREET
City
STOCKTON
SITE_LOCATION
3906 E FOURTH STREET
RECEIVED_DATE
10/17/1988
P_LOCATION
BROWN
Supplemental fields
FilePath
\MIGRATIONS\F\FOURTH\3906\88-2771.PDF
QuestysFileName
88-2771
QuestysRecordID
1771167
QuestysRecordType
12
Tags
EHD - Public
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` �S' <br /> r- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S ' <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED °'��-� <br /> (Complete in Triplicate) 4&V7 <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. <br /> Job Address r <br /> City Lot Size 1�� _ PM <br /> Owner's Name Address d Phone <br /> Contractor Address e5r 61 License ho. Phone <br /> TYPE OF WELL/POMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION [7 <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 5 Manteca _ Dia. of Well.Excavation Dia. of-Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (� <br /> 1-1 Publicion F Other 171 Delta Depth of Grout Seal Type of Grout _ <br /> i I Irrigaat ,Approx. Depth I ) 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 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION (No septic system permitted if public sewer is <br /> available within 2'0� <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 F Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS n Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t 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 mu II for all fired ins tions. Complete drawing on revers d <br /> Signed X r Title: /y <br /> Date: _�Qr•/ <br /> RTMENT USE ONLY ! ,� <br /> Application Accepted by Date_� Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Datet 1 3� <br /> Additional Comments: <br /> ❑ Sik 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, Sik., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> �.EH 13-24(REV.tiKsl 35 rr/v 1 �I <br /> EH 11-26 <br />
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