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84-612
EnvironmentalHealth
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120 (STATE ROUTE 120)
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2732
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4200/4300 - Liquid Waste/Water Well Permits
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84-612
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Last modified
11/19/2024 4:00:35 PM
Creation date
12/1/2017 3:23:28 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
84-612
STREET_NUMBER
2732
STREET_NAME
STATE ROUTE 120
City
MANTECA
SITE_LOCATION
2732 HWY 120
RECEIVED_DATE
5/18/1984
P_LOCATION
LOZONO
Supplemental fields
FilePath
\MIGRATIONS\O\120 (HWY 120)\2732\84-612.PDF
QuestysFileName
84-612
QuestysRecordID
1889767
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 City ENtiAk1,_�Critnr Size PM <br /> Owners Name _ [ZNJ 111 Address t T Phone n <br /> Contractor's Name I✓v\1 R��\'�1hU.L; 4 _ Phone (+�✓ <br /> cense No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �f <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 501 <br /> Depth Filler Material Welow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [L--I EPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Res'dence L�Commercial_ Other <br /> Number of living units: Number of bedrooms-2 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/MfgY' Capacity_1_� 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 SlYt Istance to nearest: Well-7 Foundation aO Property Line S <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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."Contractors hiring orsub-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 /> '71on laws of California. <br /> h. ust cal for �rired i s ctio s. drawing on reverse side. q <br /> Si Title:. �(�„ � � Date: r <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted b Data _ Klt Ar a `3 <br /> Pit or Grout Inspection by Date Final Inspection by _ Date _L� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 36.9-3621 anteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental ealth ermit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED 0SHRECEIVED BY DATE P RMIT`NO. <br /> + EH13-241REV.14183) <br /> EH 1428 ��Y <br />
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