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89-238
EnvironmentalHealth
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AUGUSTA
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4200/4300 - Liquid Waste/Water Well Permits
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89-238
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Last modified
12/30/2019 10:10:21 PM
Creation date
12/5/2017 7:28:30 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-238
PE
4380
STREET_NUMBER
570
STREET_NAME
AUGUSTA
STREET_TYPE
ST
City
WOODBRIDGE
SITE_LOCATION
570 AUGUSTA ST WOODBRIDGE
RECEIVED_DATE
02/02/1989
P_LOCATION
SARAH LOCKLIN
Supplemental fields
FilePath
\MIGRATIONS\A\AUGUSTA\570\89-238.PDF
QuestysFileName
89-238
QuestysRecordID
1649634
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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 5 70 A� U, `N t1 City(_J t, Lot Size / 4 P� PM <br /> Owner's Name Se.;( 60'(C It r Address L,I CLAL ib 109 Phone <br /> Contractor r1` >-`% 9 i l Ai h Address�� 1'f� y a- (Od/-License Nof �q= hone &� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR-X OTHER ❑ <br /> j r <br /> DISTANCE TO NEAREST: SEPTIC TANK i% ���1 SEWER LINES —� -- DISPOSAL FLD. PROP. LINE ��- <br /> FOUNDATIC + ** 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 /> FI Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _. <br /> I I Irrigation _.Approx. Depth tI I Eastern Surface Seal Installed by <br /> Repair Work Done X, Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No 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 Di§trict. <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 call for all required inspections. Corflplete drawing on reverse side. <br /> Signed X Gt- —ts—�-D/islt+�'`� Title: r'� r,, Date: C <br /> FOR DEPARTMENT USE ONLY _C� <br /> Application Accepted by L / 1/ Date2_"2-- � Area <br /> Pit or Grout Inspection by ate Final Inspection by -F- Date Cx` <br /> Additional Comments: <br /> ❑ Stk 466-6781 M Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Av ., .0. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> +.EH 13.24(REV.1/n s) <= <br /> Tq <br /> EH 14-28 <br />
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