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87-4373
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-4373
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Entry Properties
Last modified
11/24/2019 10:06:51 PM
Creation date
12/5/2017 6:31:51 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-4373
PE
4221
STREET_NUMBER
306
Direction
S
STREET_NAME
ANTHONY
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
306 S ANTHONY AVE STOCKTON
RECEIVED_DATE
12/28/1987
P_LOCATION
SANTIAGO GARIBAY
Supplemental fields
FilePath
\MIGRATIONS\A\ANTHONY\306\87-4373.PDF
QuestysFileName
87-4373
QuestysRecordID
1643816
QuestysRecordType
12
Tags
EHD - Public
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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ,N0� ( <br /> Telephone (209) 466-6781 11 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED tvo1� <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 /> FJob <br /> earth District. <br /> dress City ZJV of Size PM <br /> s Name ddress Phone <br /> torL-1 Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: RTIC T SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION RICULTURE WELL OTHER WELL PITS/SUMPS r- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of cavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation __.Approx. Depth I 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 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO INo septic system permitted if public sewer is <br /> available within 200 feet.) <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 Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Ll 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 of California." <br /> The applicant must call f all required inspections. Complete drawing on reverse side. d� <br /> 1 Signed X Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date (.Z't� Z_1�®Area <br /> Pit or Grout Inspection by pte Final Inspection by� U-tAC.t-�C-.�t. Date <br /> Additional Comments: __ re"Y� C alt' 7-s— <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Q35-6385 <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 RECEIVED BY DATE PERMIT'NO. <br /> INF A <br /> + EH 13-24 MEV.1/x 5) <br /> EH 14-26 Y cs <br />
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