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85-1314
EnvironmentalHealth
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ALPINE
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4200/4300 - Liquid Waste/Water Well Permits
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85-1314
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Last modified
8/21/2019 10:10:33 PM
Creation date
12/5/2017 6:04:37 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
85-1314
PE
4211
STREET_NUMBER
4590
STREET_NAME
ALPINE
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
4590 ALPINE RD STOCKTON
RECEIVED_DATE
10/28/1985
P_LOCATION
DON BACHELOR
Supplemental fields
FilePath
\MIGRATIONS\A\ALPINE\4590\85-1314.PDF
QuestysFileName
85-1314
QuestysRecordID
1639333
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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) <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 <br /> Ci Lot Size a PM <br /> Owner's Name �'� J r [L��eeE ddress �'� Phone <br /> Contractor's Name -k" icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 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 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence I— Commercial_ Other <br /> Number of living units: 'Number of b rooms r <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 <br /> In Disposals <br /> Distance to nearest: Well 4 Foundation� Property Line "'"� — <br /> ho OW <br /> LEACHING LINE ❑ No. & Length of lines Vp _' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation lb—/7 Property Line <br /> SEEPAGE PITS A Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 m t call for all require ctions. Complete dr ring on erse side. Sr <br /> Signed Title: r�—�� �"'� Date: <br /> OR DEPARTMENT USE ONLY /? <br /> Application Accepted by Date e) Area / <br /> Pit or Grout Inspection by Date �0 Final Inspection by Date`b <br /> Additional Comments: <br /> 1*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 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH r <br /> + EEH 13-24 H 14-28(REV.10/83) <br />
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