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83-729
EnvironmentalHealth
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ADELBERT
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4200/4300 - Liquid Waste/Water Well Permits
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83-729
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Entry Properties
Last modified
8/7/2019 11:43:32 PM
Creation date
3/20/2018 10:35:33 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
83-729
PE
4210
STREET_NUMBER
409
Direction
S
STREET_NAME
ADELBERT
City
STOCKTON
SITE_LOCATION
409 S ADELBERT STOCKTON
RECEIVED_DATE
7/20/1983
P_LOCATION
WM J THOMAS
Supplemental fields
FilePath
\MIGRATIONS\A\ADELBERT\409\83-729.PDF
QuestysFileName
83-729
QuestysRecordID
1631699
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 PERMIT NO. <br /> (/ Telephone (209) 466-6781 DATE ISSUED :Z,o�-� <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 <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Ruled Re ulations of the Sa Joaquin Local Health District. <br /> s a <br /> Job Address C ' t' Subdivision Name - <br /> Owner's Name h-., -o Address 4— l Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ }J <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l�l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J IndVstrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public CJ Other ❑ Delta <br /> Type of Casing <br /> ❑j Irrigation Approx. ❑ Eastern <br /> ❑Cathodic Protection Depth Specifications <br /> ❑Geophysical Depth of Grout Seal <br /> Type of Grout <br /> LJ Other <br /> 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') _44 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION )( (No septic tank or seepage pit permitted if public sewer is ,rc _ <br /> available within 200 feet.) vl <br /> Installation will serve: Residence _� Commercial _ Other <br /> Number of living units: [ Number of bedrooms c"=\,- Lot size [ 01 _�l13D <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. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line rV <br /> DESTRUCTION ❑ ^, <br /> LEACHING LINE ❑ No. & Length of lines 2 y O Total length/size Q . <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth g;L,f Size Number <br /> SUMPS D_p� 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 <br /> ordinances, state laws, and 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 <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X �.��4_9_ ��s-M 0� Title: _A� 7 V_Q � Date: ? <br /> R D_E ARTME <br /> Application Accepted bSE ONLYArea Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by keA/L Date ❑ Manteca 823-7104 <br /> Final Inspection by T Date (❑ 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 BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> I S , �! S , a 7-�--53 4s 3 7 a <br /> EH 13-24 REV. 10/82 ��� J 10/82 500 <br /> 14-26 <br />
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