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85-556
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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85-556
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Entry Properties
Last modified
8/25/2019 10:06:45 PM
Creation date
12/1/2017 3:49:00 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
85-556
STREET_NUMBER
21435
Direction
S
STREET_NAME
OLEANDER
STREET_TYPE
AVE
City
MANTECA
SITE_LOCATION
21435 S OLEANDER AVE
RECEIVED_DATE
5/28/1985
P_LOCATION
GREG HUBER
Supplemental fields
FilePath
\MIGRATIONS\O\OLEANDER\21435\85-556.PDF
QuestysFileName
85-556
QuestysRecordID
1882890
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE l ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 9 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 Ryles and Regulations of the San Joaquin <br /> Local Health District, <br /> Job Address City Lot Size PM <br /> Owner's Name /�- /S �/_ !� Address Phone <br /> Contractor r�, Address4g � License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK X SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS n ` <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 U7 <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 50'f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <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 CD_ <br /> SEPTIC TANK rk Type/Mfg & Capacity �-La Le No. Compartments Z <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> �Z— <br /> ,LEACHING LINE +lid- No. & Length of lines Total length/size <br /> FILTER BED _$C-- Distance to nearest: Well—Z-,0T—tO— Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 wi : "I ce ' that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion Paws Califor ia." /7 <br /> The app} ani mus II or Ire u re in cions. Complete drawing on r ve dside. r C I <br /> Signed Title: �` Date: S <br /> FOR P RTMENT USE O Y <br /> Application Accepted by Date AFArea 3 <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 8356385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �"' D�ATTEe PERMIT``N—O. <br />
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