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89-575
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ADELBERT
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4200/4300 - Liquid Waste/Water Well Permits
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89-575
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Last modified
1/8/2020 10:13:30 PM
Creation date
3/20/2018 10:36:41 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-575
PE
4221
STREET_NUMBER
516
Direction
S
STREET_NAME
ADELBERT
City
STOCKTON
SITE_LOCATION
516 S ADELBERT STOCKTON
RECEIVED_DATE
3/14/1989
P_LOCATION
EMMA J MEAD
Supplemental fields
FilePath
\MIGRATIONS\A\ADELBERT\516\89-575.PDF
QuestysFileName
89-575
QuestysRecordID
1631782
QuestysRecordType
12
Tags
EHD - Public
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r , <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i 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 S16 � ��4"' �e Q,� City J rT7C� Lot Size PM <br /> Owner's Name � /JytLC - ��`'e �`Ck Address �� fly ' 7 �' r� Phone -— - <br /> Contractor ay Address `� License No. Phone_ <br /> if <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 /> ❑ 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 <br /> rout --_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 501 <br /> Depth Filler Material (Below 50'1 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> (` <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) G <br /> Number of living units: Number of bedrooms r— <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 1 <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 o lifornia" <br /> The a ica m st call or all required i ctions. Complete drawing on reverse side. <br /> Signed Title: Dater�f <br /> FOR DEPARTMENT USE ONLY p77 <br /> Application Accepted by ��J ���L Datef — ` Area <br /> Pit or Grout Inspection by Date JJ Final Inspection by p- Date <br /> Additional Comments: (�IS��13 le,ac- Co tee. (191.M1GYS L�tl ? 7 s�wfic *4,x 4,fk a <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. <br /> +.EH13.24(REV. <br />
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