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86-964
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4200/4300 - Liquid Waste/Water Well Permits
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86-964
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Last modified
9/9/2019 10:26:53 PM
Creation date
3/20/2018 11:06:16 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
86-964
PE
4370
STREET_NUMBER
20498
Direction
S
STREET_NAME
AIRPORT
STREET_TYPE
WY
City
MANTECA
SITE_LOCATION
20498 S AIRPORT WY MANTECA
RECEIVED_DATE
08/07/1986
P_LOCATION
TUBBS & SONS ELECTRIC
Supplemental fields
FilePath
\MIGRATIONS\A\AIRPORT\20498\86-964.PDF
QuestysFileName
86-964
QuestysRecordID
1633599
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR�PERMIT _ip— <br /> SAN JOAaUIN LOCAL HEALTH DISTRICT <br /> y� 1601 E. HAZEL 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 Zo"f�a �� /tt/t- ®�.� City Lot Size PM <br /> Owner's Name \r /J Y(- CXR CM e Address 7LJl N- Nl aM A.J t. A&W i�f(,t/ Phone <br /> Contractor Address - l icense No. o��Ul. Phone <br /> TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK /DD SEWER LINES DISPOSAL FLD. /DD PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLS 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 X Gravel Pack ❑ Tracy Type of Casing 10W_ Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal J. Type of Grout `U <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 (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is c n <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 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line , <br /> SEEPAGE PITS ❑ Deptb Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ A. <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,1 shall employ persons subject to workman's compensa- <br /> tion laws of Cal'ornia." <br /> The appli ant at call fpr all requir inspection . Complete drawing on r verse si . <br /> Signed Title: Date: <br /> ,f 7FOR DEPA MENT USE ONLY f3 <br /> Application Accepted by �' Date V Area /_R <br /> Pit or Grout Inspection by Date. Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.63% <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 CASH RECnEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.1/8 5) ' ® ��l '� ' \` 17 //T �6_ci <br /> EH 14-26 �+l - b <br />
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