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89-1524
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4200/4300 - Liquid Waste/Water Well Permits
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89-1524
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Last modified
12/23/2019 10:09:56 PM
Creation date
12/1/2017 3:03:09 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-1524
STREET_NUMBER
2328
STREET_NAME
YOUNG
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
2328 YOUNG AVE
RECEIVED_DATE
6/29/1989
P_LOCATION
MAX & CYNTHIA PEREZ
Supplemental fields
FilePath
\MIGRATIONS\Y\YOUNG\2328\89-1524.PDF
QuestysFileName
89-1524
QuestysRecordID
1997829
QuestysRecordType
12
Tags
EHD - Public
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i- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � � ? r��� 7 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �`' j ' <br /> k. <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 $ Tbv+�.� 7City Lot Size PM <br /> c <br /> rte *4 C_ Phone� �?` f7 <br /> Owner's Name At 1 Address <br /> Contractor �' �{"C" Address License No. Phone <br /> TY E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO T: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FO AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL ONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of a ion Dia. of Well Casing <br /> A(Domestic/Private 0.Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Ll Other M Delta Depth of Grout Seal f 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 50') -- <br /> TYPE-OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> vaiiable within 200 feet.) <br /> Installation will serve: Residence 1X_ Commercial_ ?Other (� <br /> Number of living units: --A- 3 Number of bedrooms C, <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 L] 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 st call far all reqgLred fgONtions. Complete drawing on reverse side. <br /> r <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ` Date <br /> Additional Comments: 0/X eon - rr1 m e n t�04. s(, 12I 2-7195 <br /> ❑ Stk 466-6781 ❑ Lodi 364-3621 ❑ Manteca 823 ❑ 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 ASH RECEIVED BY� DATr—' PERMIT'NO. <br /> INFO pG JJ <br /> EH 113-241REV.tik 51 �—Z�ra_1 �'� +5z <br /> EH 114.26 !!!! <br />
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